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Digitized  by  tine  Internet  Archive 

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Open  Knowledge  Commons 


http://www.archive.org/details/surgicaldiagnosiOOberg 


SURGICAL  DIAGNOSIS 


A   MANUAL 


STUDENTS  AND  PEACTITIONERS 


BY 


ALBERT  A.  BERG,  M.D. 

ADJUNCT    ATTENDING    SURGEON    TO    THE    MOUNT    SINAI    HOSPITAL,    NEW  YORK 


ILLUSTRATED  WITH  215  ENGRAVINGS  AND  21    PLATES 


LEA  BROTHERS  &  CO. 

NEW    YORK    AND    PHILADELPHIA 

1905 


Entered  according  to  the  Act  of  Congress,  in  the  year  1905,  by 

LEA  BROTHERS   &   CO., 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


DORNAN,    PRINTER 


TO    THE 

MEMORY    OF    MY     PARENTS 

AND 

TO      MY      TEACHER      AND      FRIEND 

DR.  A.  G.  GERSTER 

THIS    BOOK   IS 

AFFECTIONATELY 

DEDICATED 


PREFACE. 


Until  the  last  few  decades  the  surgeon's  efforts  were 
limited  to  organs  lying  on  the  surface  and  directly  accessible. 
Aseptic  methods  and  improvements  in  operative  technique 
have  meantime  brought  the  internal  organs  within  the  range 
of  successful  treatment,  and  this  enlargement  of  the  surgical 
field  has  necessitated  the  introduction  of  new  methods  of 
diagnosis  and  improvements  upon  the  old.  In  the  present 
volume  the  author  has  endeavored  to  cover  the  whole  subject 
concisely  and  in  its  modern  development. 

The  light  that  has  been  thrown  upon  the  early  stages  of 
disease-processes  by  laparotomy  and  exploratory  incision, 
the  close  analysis  and  classification  of  the  clinical  manifes- 
tations of  individual  diseases  that  have  been  made  by  those 
who  have  the  opportunity  for  observing  large  numbers  of 
patients,  and  the  aid  that  the  pathological,  bacteriological, 
and  chemical  laboratories  afford  for  the  interpretation  of 
the  phenomena  of  disease  have  made  it  possible  to  recognize 
most  of  the  maladies  that  are  surgical  in  character  at  their 
incipiency.  There  still  remain,  however,  some  diseases 
which  we  cannot  even  to-day  diagnosticate  early,  notably 
cancer  of  the  internal  organs.  It  is  to  be  hoped  that 
continued  exploratory  incision  and  further  clinical  observa- 


vi  PREFACE 

tion  will  soon  give  the  data  necessary  for  the  early  recognition 
of  these  maladies. 

The  author  has  endeavored  to  present  surgical  diagnosis 
in  a  clear  and  definite  way  to  meet  the  needs  of  students 
and  general  practitioners.  He  has  also  presented  the  methods 
of  diagnosis  of  kidney  function,  the  diagnosis  of  diseased 
conditions  of  the  kidney  from  the  appearance  of  the  ureteral 
orifice,  the  early  diagnosis  of  tuberculous  disease  of  the 
articular  ends  of  bones,  etc.,  which  he  hopes  will  be  of 
especial  interest  to  his  colleagues  in  surgery.  Consideration 
of  the  best  method  of  developing  the  subject  for  his  readers 
has  led  him  first  to  give  a  concise  clinical  picture  of  each 
disease,  including  its  causes,  onset,  and  course,  and  in  cer- 
tain cases  the  accompanying  pathological  changes.  In  each 
instance  he  has  indicated  the  points  of  difference  between 
the  disease  under  discussion  and  diseases  of  other  organs 
which  might  be  mistaken  for  it. 

The  author  takes  this  opportunity  of  thanking  Drs. 
Gerster,  Lilienthal,  and  Ware  for  the  privilege  of  reproducing 
photographs  of  their  cases;  also  Drs.  Brickner,  Foord,  and 
Sternberg,  of  the  a;-ray  department  of  Mt.  Sinai  Hospital, 
for  the  skiagraphs  that  are  here  presented,  and  Dr.  Bren- 
nauer,  of  the  house  staff  of  Mount  Sinai  Hospital,  for  taking 
most  of  the  photographs.  His  thanks  are  likewise  due  to 
Drs.  Leo  Meyer  and  Milton  Gershel  for  aid  in  revising  the 
manuscript,  and  to  his  publishers  for  their  unfailing  courtesy 
during  the  preparation  of  this  book. 

A.  A.   B. 

923  Madison  Ave.,  New  York,  1905. 


CONTENTS. 


PART  I. 

GENERAL  CONSIDERATIONS  ON  DIAGNOSIS. 
CHAPTER  I. 

PAGE 

The  Examiner — The  Taking  of  the  CHnical  History — The  Exam- 
ination of  the  Patient — The  Use  of  Instruments  for  Diagnos- 
tic Purposes — General  Considerations  on  Instruments  .        17 

CHAPTER  II. 

THE   CLINICAL    SIGNIFICANCE   OP   GENERAL   SYMPTOMS   IN   SURGICAL 
DISEASES. 

Cachexia — Emaciation — Jaundice — Pain — Head  Zones — -Muscu- 
lar Rigidity — Reflex  Muscular  Spasm — Fever — Pulse  Rate 
— Respiration  Rate — Anaemia — Leukocytosis     ...       23 

CHAPTER  III. 

SURGICAL   INFECTIONS. 

The  Constitutional  Symptoms  of  Toxin  Absorption — Toxaemia, 
Septicsemia,  Pysemia^ — The  Local  Lesions  Resulting  from 
Wound  Infections — Abscess — Sinus — Fistula — Ulceration — 
Gangrene — Erysipelas — ^Anthrax        .....        43 


PART  11. 

INJURIES  AND  DISEASES  OF  THE  HEAD  AND  NECK. 
CHAPTER  IV. 

TUMORS   AND   INFLAMMATORY   DISEASES   OF   THE   HEAD. 

Congenital  Tumors — Neoplasms  of  the  Scalp — Diseases  of  the 

Skull 53 


viii  CONTENTS 

CHi^PTER  V. 

INJURIES    OF    THE    HEAD. 

PAGE 

Cerebral  Concussion — Cerebral  Compression — Cerebral  Laceration 
— Injuries  of  the  Cranial  Nerves — Coma  in  Cerebral  Injuries 
— Localization  of  Cerebral  Lesions — Hemiplegia — Hemianses- 
thesia  —  Hemianopsia  —  Nystagmus  —  Aphasia  —  Ataxia  — 
Cheyne-Stokes  Breathing — Traumatic  Diabetes — The  Lesions 
of  the  Soft  and  Bony  Capsules  .  .  ...  .65 

CHAPTER  VI. 

INFLAMMATIONS   AND   NEOPLASMS    OF   THE    BRAIN   AND   ITS   MEMBRANES. 

Meningitis — Acute  Suppurative  EncephaHtis — Chronic  Suppura- 
tive Encephalitis — Localization  of  Cerebral  Abscess — Sinus 
Thrombosis — Locahzation  of  Thrombosed  Sinus — Intra- 
cranial Neoplasms  .  .  .  .  .  .  .78 

CHAPTER  VII. 

INJURIES,    INFLAMMATIONS,    AND   NEOPLASMS   OF   THE   FACE. 

Lupus  Vulgaris — Syphihs — Epithelioma — Fractures  of  the  Jaw 
— Dislocation  of  the  Jaw — Inflammation  of  the  Maxillary 
Bones — Hydrops  of  Maxillary  Bones — Empyema  of  Antrum 
of  Highmore — Neoplasms  of  the  Maxillary  Bones      .  .       88 

CHAPTER  VIII. 

INFLAMMATIONS    AND    NEOPLASMS    OP    THE    MOUTH,     TONGUE,    TONSILS, 
PHARYNX,    AND    SALIVARY    GLANDS. 

Aphthffi  —  Soor  —  Stomatitis  —  Glossitis  —  Tuberculosis  of  the 
Tongue — Syphilis  of  the  Tongue — ^Actinomycosis  of  the 
Tongue — Cancer  of  the  Tongue — Diseases  of  the  Tonsil  and 
Nasopharynx — Tumors  of  the  Floor  of  the  Mouth — Acute 
Inflammation  of  the  Salivary  Glands — Ranula — Salivary 
Calculus — Tumors  of  the  Sahvary  Glands — Tumors  of  the 
Parotid 103 

CHAPTER  IX. 

INFLAMMATORY    DISEASES    OF    THE    NECK. 

Angina  Ludovici  —  Retropharyngeal  Abscess  —  Carbuncles  — 
Furuncles  —  Anthrax  Pustules  —  Tuberculous  Glandular 
Abscesses — Actinomycosis         ......     123 


CONTENTS  ix 

CHAPTER  X. 

TUMORS    OF    THE    NECK. 

PAGE 

Lymphatic  Glandular  Tumors  —  Characteristics  of  Glandular 
Tumors — Simple  Hyperplasia — Tuberculous  Hyperplasia — 
Pseudoleuksemic  Hyperplasia  —  Sarcomatous  Hyperplasia  - 
Syphilitic  Hyperplasia  —  Miscellaneous  Tumors  —  Branchio- 
genetic  Cysts  —  Congenital  Cystic  Hygroma  —  Cavernous 
Lymphangioma  —  Enlarged  Bursse  —  Echinococcus  Cysts 
— Blood  Cysts  —  Angiomata  — -  Aneurysms  —  Fibroma  — 
Lipoma  —  Cervical  Rib  —  Malignant  Neoplasms  —  Thyroid 
Tumors — Fistulse  and  Sinuses  of  the  Neck       .  .  .     130 

CHAPTER  XI. 

DISEASES    OP   THE    LARYNX FOREIGN    BODIES    IN    THE    LARYNX   AND 

BRONCHI. 

Method  of  Laryngoscopic  Examination — Symptoms  of  Disease 
of  the  Larynx — Acute  Laryngeal  Stenosis — Acute  Laryngitis 
— Diphtheritic  Croup — Spasmodic  Croup — CEdema  of  the 
Structures  of  the  Glottis — Foreign  Bodies  in  the  Larynx  and 
Bronchi — Wounds  and  Fractures  of  the  Larynx — Tubercu- 
lous Laryngitis — Syphilitic  Laryngitis — Neoplasms  of  the 
Larynx —  Pachydermatous  Laryngitis — Chondritis — Stric- 
ture of  the  Larynx — Compression  of  the  Larynx       .  .      158 


PART  III. 

INJURIES  AND  DISEASES  OF  THE  THORAX. 
CHAPTER  XII. 

INJURIES   OP  THE   THORAX. 

Concussion  of  the  Thorax — Injuries  of  the  Thoracic  Wall — Injuries 
of  the  Lungs  and  Pleura — Injuries  of  the  Heart  and  Peri- 
cardium— Injuries  of  the  Large  Thoracic  Bloodvessels — 
Injuries  of  the  ffisophagus — Injuries  of  the  Diaphragm     .     171 

CHAPTER  XIII. 

INFLAMMATIONS    AND    NEOPLASMS    OP    THE    CHEST   WALL. 

Acute    Suppuration  —  Chronic    Suppuration  —  Neoplasms    of 

the  Chest  Wall       . 178 


X  CONTENTS 

CHAPTER  XIV. 

DISEASES    OF    THE    BREAST. 

PAGE 

Clinical  History  and  Method  of  Examination  of  Diseased  Breast 
— Acute  Inflammation  and  Suppuration — Chronic  Inflam- 
mation— Hypertrophy — Tuberculosis — Neoplasms — Diseases 
of  the  Nipple .  .183 

CHAPTER  XV. 

DISEASES   OP   THE   PLEURA   AND   LUNGS. 

Empyema  —  Sacculated    Empyema  —  Gangrene    and    Abscess 

of  the  Lung — Neoplasms  of  the  Lung — Cysts  of  the  Lung    .      192 

CHAPTER  XVI. 

DISEASES    OF    THE    MEDIASTINUM. 

Symptoms  of  Mediastinal  Disease — Enlarged  Mediastinal  Glands 
— Neoplasms  of  the  Mediastinum — Suppuration  in  the 
Mediastinum 204 

CHAPTER  XVII. 

DISEASES    OP   THE    CESOPHAGUS. 

Disturbances  in  Muscular  Action  of  the  (Esophagus — Clinical  Evi- 
dences of  Disturbances  in  the  Lumen  of  the  (Esophagus — 
Physical  Examination  of  (Esophagus — (Esophagoscope  in 
Diseases  of  the  (Esophagus        .  .  .  .  .  .     209 


PART  IV. 

INJURIES  AND  DISEASES  OF  THE  ABDOMEN. 
CHAPTER  XVIII. 

GENERAL     REMARKS     ON     ABDOMINAL     DIAGNOSIS     AND     EXAMINATION. 

Exploratory  Laparotomy — Method  of  Physical  Examination  of 
Abdomen — Inspection  —  Palpation — Percussion — Ausculta- 
tion—Probatory  Puncture        .  .  .  .  .  .219 


CONTENTS  xi 

CHAPTER  XIX. 

DISEASES   OF  THE  ABDOMINAL  WALL  AND   INJURIES  OP  THE  ABDOMEN. 

Tumors,  Swellings,  and  Exudates  of  the  Abdominal  Wall — Tears   ^^'^^ 
and  Ruptures  of  the  Abdominal  Muscles — Contusions  of  the 
Abdomen — Open  Wounds  of  the  Abdomen        .  .  .      231 

CHAPTER  XX. 

HERNIA. 

Varieties  of  Hernice:  Inguinal  —  Superficial  Inguinal  —  Properi- 
toneal  Inguinal  —  Femoral  —  Obturator  —  Hemise  of  the 
Umbilical  Cord  —  Hemise  at  the  Umbilicus  —  Ventral 
Hemise  —  Epigastric  Hernise  —  Diastasis  of  the  Recti 
Muscles — Hernia  at  Linea  Senciilunaris — Hemia  through 
the  Triangle  of  Petit — Hernise  after  Laparotomy.  Contents 
of  Hernice:  Complications  of  Hernice — IrreducibUity — Inflam- 
mation —  Obstruction  —  Torsion  of  Contents  —  Strangula- 
tion.   Differential  Diagnosis  of  Special  Hernice     .  .  .     237 

CHAPTER  XXI. 

DISEASES    OF    THE    PERITONEUM ASCITES SUBPHRENIC    ABSCESS. 

Acute  Infective  Peritonitis — Peritoneal  Septicsemia — Circum- 
scribed Peritonitis — Chronic  Adhesive  Peritonitis — Tuber- 
culous Peritonitis  —  Ascites  —  Subphrenic  Abscess     .  .     248 

CHAPTER  XXII. 

DISEASES    OF    THE    STOMACH. 

Method  of  Examination  of  the  Stomach  and  its  Secretion — • 
Composition  of  the  Gastric  Juice — Ulcer  of  the  Stomach 
— Neoplasms  of  the  Stomach     ......     258 

CHAPTER  XXIII. 

DISEASES  OF  THE  STOMACH  (Continued). 
Pyloric  Stenosis — Acute  Dilatation  of  the  Stomach — Hour-glass 

Stomach  .........      270 

CHAPTER  XXIV. 

PERFORATIONS    INTO    THE    PERITONEAL    CAVITY. 

Perforations  with  and  ^vithout  Extravasation  of  Infected  Material 
— Symptoms  of  Perforation — Perforations  of  the  Special 
Viscera  .  . 274 


xii  CONTENTS 


CHAPTER  XXV. 


INTESTINAL    OBSTRUCTION. 


PAGE 


Symptoms  of  Acute  Obstruction — How  to  Determine  its  Pres- 
ence— Character  of — Causes  of — Site  of — Symptoms  of 
Clironic  Obstruction — Site  of — Character  of       .  .  .      280 

CHAPTER  XXVI. 

DISEASES    OF    THE    APPENDIX    VERMIFORMIS. 

Site  of  Appendix — Method  of  Palpation  of — How  to  Estimate  the 
Severity  of  Inflammation  of — Acute  Follicular  Appendicitis 
— Acute  Ulcerative  and  Gangrenous  Appendicitis — Septi- 
.  csemia  and  Septicopyemia  in — Differential  Diagnosis  of         .      285 

CHAPTER  XXVII. 

NEOPLASMS    OF    THE    INTESTINE,    MESENTERY,    AND    OMENTUM. 

Neoplasms  of  the  Intestines — Cystic  Tumors  of  the  Mesentery 
— Solid  Tumors  of  the  Mesentery — Omental  Tumors — Tor- 
sion of  the  Omentum       .......      296 

CHAPTER  XXVIII. 

DISEASES    OF    THE    LIVER. 

Position  and  Palpation  of  the  Liver — Abnormal  Lobes  of  the 
Liver — Floating  Liver — Congenital  Malposition  of  the 
Liver — Abscess  of  the  Liver — Hydatid  Cyst  of  the  Liver — 
Non-parasitic  Cysts  of  the  Liver — Cystic  Degeneration  of 
the  Liver — Solid  Neoplasms  of  the  Liver — Syphilis  of  the 
Liver 300 

CHAPTER  XXIX. 

DISEASES    OF    THE    GALL-BLADDER. 

Position  and  Method  of  Palpation  of  the  Gall-bladder — Chole- 
lithiasis— -Passage  of  Gallstones  through  Biliary  Channels 
— Impaction  of  Gallstones  in  Biliary  Passages — Infection  of 
the  Biliary  Apparatus — Ulceration  of  Gallstones  through  the 
Biliary  Channels — Determination  of  Site  of  Gallstones — 
Differential  Diagnosis  of  Gallstone  Disease  and  Enlarge- 
ments of  the  Gall-bladder — Carcinoma  of  the  Gall-bladder 
— Carcinoma  of  the  Bile-ducts  ......     314 


CONTENTS  xiii 

CHAPTER  XXX. 

DISEASES    OF    THE    PANCREAS. 

PAGE 

Position  of  the  Pancreas — Fat  Necrosis  in  Diseases  of  the  Pan- 
creas— Acute  Inflanamation  of  the  Pancreas — Pancreatic 
Hemorrhage  and  Necrosis — Pancreatic  Abscess — Chronic 
Inflammation  of  the  Pancreas — Cysts  of  the  Pancreas — 
Malignant  Tumors  of  the  Pancreas — Pancreatic  Calculi      .      324 

CHAPTER  XXXI. 

DISEASES    OP    THE    SPLEEN. 

Position  of  the  Spleen — Movable  Spleen — Abscess  of  the  Spleen 
— Rupture  of  the  Spleen — Neoplasms  of  the  Spleen — Leu- 
ksemic  Spleen  ........     339 

CHAPTER  XXXII. 

DISEASES    OP    THE    PEMALE    PELVIC    ORGANS. 

Method  of  Examination  of  the  Female  Pelvic  Organs — Fibro- 
myomata  of  the  Uterus — Malignant  Tumors  of  the  Uterus 
—Inflammations  of  the  Fallopian  Tubes — Extrauterine 
Pregnancy      .........     343 

CHAPTER  XXXIII. 

DISEASES  OP  THE  PEMALE  PELVIC  ORGANS  (Continued). 
Inflammations  of  the  Ovary — Neoplasms  of  the  Ovary      .  .     354 

CHAPTER  XXXIV. 

DISEASES    OP    THE    RECTUM. 

Method  of  Examination  of  the  Anus  and  Rectum — Atresia  of  the 
Anus  and  Rectum — Prolapse — Hemorrhoids — Inflammation 
and  Ulceration  —  Stricture  —  Neoplasms  —  Polypi  — 
Periproctitis — Fistula.      .......     361 


PART  V. 

INJURIES  AND  DISEASES  OF  THE  GENITOURINARY  ORGANS. 
CHAPTER  XXXV. 

DISEASES    OF    THE    KIDNEY. 

General  Considerations  on  the  Diagnosis  of  Kidney  Disease:  The 
Anamnesis  —  Physical  Examination  —  Exploratory  Punc- 
ture —  Urinary  Examination  —  Cystoscopic  Examination 
—  -X'-ray  Examination  —  Determination  of  Kidney  Func- 
tion         369 


xiv  CONTENTS 

CHAPTER  XXXVI. 

MALFORMATIONS    AND    DISPLACEMENTS    OF   THE    KIDNEY. 

PAGE 

Absence  of  One  Kidney — Fusion — Congenital  Sacral  Kidneys — 

Multiple  Ureters — Nephroptosis  and  Mobile  Kidney     .  .      382 

CHAPTER  XXXVII. 

INFLAMMATIONS    OF    THE    KIDNEY. 

Suppuration  of  the  Kidneys — Hydronephrosis — Pyonephrosis — 

Tuberculosis  of  the  Kidney      ......     386 

CHAPTER  XXXVIII. 

RENAL   STONE  ....       395 

CHAPTER  XXXIX. 

NEOPLASMS    OF    THE    KIDNEY. 

Benign  Tumors  —  Malign  Tumors  —  Cystic  Tumors  —  Adrenal 

Tumors 398 

CHAPTER  XL. 

DISEASES    OF   THE    URETER. 

Injuries — Inflammations — Kinks  and  Strictures — -Neoplasms      .     401 
CHAPTER  XLI. 

DISEASES    AND    INJURIES    OF    THE    URINARY    BLADDER. 

Symptoms  of  Vesical  Disease — Cystoscopic  Appearances  in  Dis- 
eases of  the  Bladder — Injuries  of  the  Bladder     .  .  .     403 

CHAPTER  XLII. 

URINARY   FISTULtE — DISTURBANCES    OF   MICTURITION. 

Fistulse — Retention  of  Urine — Incontinence  of  Urine — Tardiness 
in  Starting  the  Stream — Diminution  in  the  Calibre  of  the 
Urinary  Stream       ........     409 

CHAPTER  XLIII. 

DISEASES   OF  THE  PROSTATE  GLAND,   POSTERIOR  URETHRA  AND  SEMINAL 

VESICLES. 

Inflammatory  Affections  —  Prostatic  Tuberculosis  —  Prostatic 
Hypertrophy  and  Atrophy  —  Urethral  Stricture  — 
Tumors  of  the  Prostate — Urethral  Calculi — Neoplasms  of 
the  Urethra 412 


CONTENTS  XV 

CHAPTER  XLIV. 

PAGE 
INJURIES     OF     THE     URETHRA     AND     URINARY     EXTRAVASATION — ■ 

URETHRAL   FEVER      .  .  .  .  .  .  .  .       420 

CHAPTER  XLV. 

DISEASES    OF    THE    EXTERNAL    GENITAL    ORGANS,    TESTICLE,    AND    CORD. 

Abnormalities  —  Ulcerations  —  Herpes  —  Benign  Nodular 
Infiltrations — Swellings  of  the  Cord — Hydrocele — Hsemato- 
cele  —  Lipoma  of  the  Cord  —  Varicocele  —  Spermatocele 
— Inflammations  of  the  Testicle  and  Epididymis — Tuber- 
culosis of  the  Testicle — Syphilis  of  the  Testicle — Neoplasms 
of  the  Testicle 423 


PART  VI. 

INJURIES  AND  DISEASES  OF  THE  EXTREMITIES. 
CHAPTER  XLVI. 

INJURIES    OF   BONES. 

X-ray  in — Method  of  Examination  for  Fracture — Special  Frac- 
tures of  the  Shafts  of  Bones      ......     435 

CHAPTER  XLVII. 

INFLAMMATIONS    AND    NEOPLASMS    OF    BONES. 

Acute  Osteomyelitis  —  Chronic  Osteomyelitis  —  Rhachitis  — 
Osteomalacia  —  Osteitis  Deformans  —  Exostoses  —  Neo- 
plasms of  Bones  —  Hydatid  Cysts  of  Bones    .  .  .     439 

CHAPTER  XLVIII. 

GENERAL  REMARKS   ON  THE   DIAGNOSIS   OF  JOINT  INJURY  AND   DISEASE 

Method  of  Examination  of  Joints — Contour  of  Limb — Position 
of  Limb — Cutaneous  Aspect  of  Limb — Muscular  Atrophy 
— Presence  of  Fluid  in  Joints — Relation  of  Fixed  Points 
around  Joints  —  Measurement  —  Motion  —  AT-ray  Exam- 
ination ..........      455 


xvi  CONTENTS 

CHAPTER  XLIX. 

INJURIES    OF   THE   JOINTS. 

PAGE 

Injuries  of  Special  Joints       .......     467 

CHAPTER  L. 

ACUTE    INFLAMMATIONS    OF    JOINTS. 

Acute  Synovitis — Acute  Arthritis  .....     481 

CHAPTER  LI. 

CHRONIC    DISEASES    OF   THE    JOINTS. 

Tuberculosis:       General     Symptoms — Differential     Diagnosis — 

Tuberculosis  of  the  Special  Joints      .....     485 

CHAPTER  LII. 
CHRONIC  DISEASES  OP  THE  JOINTS  {Continued). 

Syphilis  of  the  Joints — Osteoarthritis — Neuropathic  Joint  Dis- 
ease— Joint  Disease  in  Haemophilia — Hysterical  Joint  Disease 
— Foreign  Bodies  in  Joints — Floating  Cartilages  .  .      512 

CHAPTER  LIII. 

INJURIES    OF    THE    SPINE. 

Fractures  —  Dislocation  —  Spinal    Cord    Concussion  —  Spinal 

Cord  Compression  and  Destruction     .  .  .  .  .519 

CHAPTER  LIV. 

TUMORS    IN    THE    SPINAL    REGION. 

Spina  Bifida — Sacral  Dermoids       ......     525 


PART  L 
GENERAL  CONSIDERATIONS  ON  DIAGNOSIS. 


CHAPTER    I. 

THE  EXAMINER— THE  TAKING  OF  THE  CLINICAL  HIS- 
TORY—THE EXAMINATION  OF  THE  PATIENT. 

Success  in  diagnosis  depends  upon  a  careful  elicitation 
of  the  patient's  history  and  symptoms  and  upon  their  logi- 
cal interpretation.  The  former  demands  from  the  examiner 
painstaking  effort  and  the  sharp  use  of  all  his  senses;  the 
latter  his  keenest  judgment.  Experience  trains  his  dis- 
criminating faculties;  it  teaches  him  the  relative  clinical 
importance  of  the  facts  that. have  been  elicited  in  the  anam- 
nesis and  examination;  it  helps  him  to  draw  conclusions 
quickly  and  accurately.  The  sharper  his  senses,  the  better 
his  judgment,  and  the  wider  his  experience,  so  much  the 
quicker  and  so  much  the  more  accurate  will  his  diagnosis 
be.  No  diagnosis  should  rest  on  intuition;  it  should  be  the 
result  of  a  rapid  examination,  a  keen  appreciation  of  the 
important  symptoms,  and  their  significance. 

For  the  beginner  in  diagnostics  it  is  essential  that  the 
investigation  into  the  history  and  the  examination  of  the 
patient  be  made  in  a  systematic  manner.  While  questioning 
the  patient,  the  examiner  should  take  note  of  his  general  char- 
acteristics: the  demeanor,  the  psychical  condition  (whether 
hysterical,  hypochondriacal,  etc.),  the  accuracy  with  which 
statements  are  made;  he  should  endeavor  to  dispel  fear,  or 
shyness,  and  to  encourage  confidence.  In  eliciting  the  clini- 
cal history,  attention  should  be  given  to  what  are  apparently 

2 


18  GENERAL   CONSIDERATIONS   ON   DIAGNOSIS 

minor  facts.  No  point  is  so  small,  no  symptom  so  slight, 
but  that  it  may  have  quite  an  important  bearing  on  the 
diagnosis. 

The  following  scheme  is  adhered  to  in  taking  clinical 
histories  at  Mount  Sinai  Hospital: 

Name,  age,  and  date  of  admission. 

Birthplace  and  occupation. 

The  family  history,  especially  in  reference  to  tuberculosis, 
malignant  disease,  syphilis. 

The  previous  personal  history,  habits,  and  in  women  the 
menstrual  cycle,  pregnancies,  and  nursing. 

The  present  illness:  its  duration,  and  to  what  it  is  attribu- 
ted; its  prodromata;  its  onset,  and  its  course.  (In  most  cases 
it  is  necessary  to  enquire  into  individual  symptoms  and 
bodily  functions — e.  g.,  the  gastrointestinal,  urinary,  genital, 
respiratory,  and  cardiac  functions.) 

The  chief  complaints,  and  the  general  appearance,  nutri- 
tion, and  strength. 

In  the  examination  of  the  patient  it  is  likewise  necessary 
to  follow  a  definite  systematic  plan.  The  patient  should 
be  undressed  sufficiently  to  permit  us  to  make  a  thorough 
physical  examination.  Very  sick  or  feeble  patients  will 
be  in  bed,  and  in  our  office  the  individual  may  be  examined 
in  the  erect  or  recumbent  position.  The  routine  examina- 
tion should  determine: 

1.  The  general  condition  of  the  patient;  the  color  of  the 
mucous  membranes  and  conjunctivse;  the  facial  expression; 
eruptions  on  the  skin;  scars;  decubitus;  the  position  of  the 
patient,  and  the  presence  of  oedema. 

2.  The  rate  and  rhythm  of  the  pulse;  the  character  of  the 
arteries  and  the  arterial  tension. 

3.  The  rate,  type,  and  character  of  the  respirations. 

4.  The  temperature. 

5.  The  physical  condition  of  the  lungs,  heart,  digestive 
organs;  of  the  abdomen,  of  the  urinary  organs,  of  the  geni- 
tals, of  the  nervous  system,  of  the  extremities,  and  of  the 
special  organs. 

6.  The  chemical  composition  and  microscopic  elements 
of  the  urine,  and,  whenever  necessary,  the  chemical  compo- 
sition of  the  gastric  juice,  the  appearance  of  the  feces,  etc. 


THE  EXAMINER  19 

Evidences  of  disease  are  detected  by  the  senses  of  sight, 
smell,  touch,  and  hearing.  As  the  former  two  disturb  the 
patient  least,  we  should  gain  all  the  information  we  can 
through  these  channels  before  proceeding  to  palpate,  per- 
cuss, or  auscultate.  It  is  surprising  how  much  laiowledge 
can  be  gained  by  sight  and  smell.  The  short,  rapid,  forced 
respirations,  with  a  flushed  face,  are  strongly  indicative  of 
pulmonary  disorder;  the  puffed  eyelids,  distended  abdomen, 
protruding  umbilicus,  and  oedema  of  the  feet  are  pathog- 
nomonic signs  of  impaired  general  circulation;  the  facial 
expression  shows  actual  pain,  anxiety,  etc.;  thoracic  respira- 
tion with  immobility  of  the  abdominal  muscles  are  indica- 
tions of  peritoneal  inflammation;  shortening  of  limbs,  axial 
deviation,  malposition  or  abnormal  position  thereof  are 
evidences  of  fracture  or  dislocation,  etc.  The  diagnosis 
can   often   be  made  by  sight  alone. 

The  sense  of  smell  likewise  gives  valuable  information; 
thus  the  sweetish  odor  of  the  breath  and  perspiration  which 
accompanies  the  septic  state,  and  the  odor  of  violets  (acetone) 
in  the  urine  and  breath,  that  is  sometimes  present  in  diabetes, 
are  important  aids  in  making  a  diagnosis  of  these  diseases.^ 

Palpation,  percussion,  and  auscultation  are  proceeded 
with  after  a  thorough  inspection  and  smell  of  the  patient. 
Here  there  is  need  of  a  light  touch  and  a  sharp  ear.  It  is 
always  a  good  rule  to  compare  any  abnormalities  with  the 
supposedly  healthy  side. 

The  information  obtained  by  these  special  sensory  organs 
is  supplemented  by  that  which  is  elicited  by  the  use  of  spe- 
cial apparatus — e.  g.,  cystoscope,  proctoscope,  hsemocytom- 
eter,  microscope,  etc. — and  finally  by  that  which  is  obtained 
by  bacteriological,  chemical,  and  histological  examination. 
It  is  to  be  remembered  that  the  clinical  evidences  of  disease 
are  the  most  important;  the  laboratory  results  aid,  elabo- 
rate, and  substantiate  the  bedside  findings;  they  never 
replace  them. 

1  The  author  knows  of  a  patient  admitted  to  the  hospital  iu  comatose  condition. 
No  history  could  be  obtained.  The  bladder  was  empty.  A  painstaking  physical 
examination  did  not  enable  the  attending  physician  to  make  an  accurate  diagnosis. 
The  lay  superintendent  who  had  admitted  the  patient  ventured  the  diagnosis  of  dia- 
betic coma  from  the  smell  of  the  patient's  breath  and  perspiration.  Subsequent 
examination  of  the  urine  proved  him  to  be  correct. 


20  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

The  advanced  diagnostician  as  well  as  the  beginner  will 
find  it  essential  to  make  the  thorough  examination  outlined 
above.  A  complete  physical  examination  is  essential  not 
only  for  making  a  diagnosis,  but  the  therapeutic  measures 
that  are  to  be  employed  frequently  depend  upon  the  con- 
dition of  the  internal  viscera.  The  symptoms  for  which  the 
patient  seeks  relief  may  be  secondary  to  a  primary  lesion 
that  is  forgotten  or  unnoticed  until  the  attention  is  directed 
to  it  by  a  thorough  examination;  or,  again,  the  existence 
of  severe  respiratory,  cardiac,  or  nephritic,  or  other  constitu- 
tional disease  may  contraindicate  a  surgical  procedure  that 
would  otherwise  have  been  employed. 


THE  USE  OF  INSTRUMENTS  FOR  DIAGNOSTIC 
PURPOSES. 

Special  instruments  for  diagnostic  purposes  are  meant  to 
serve  one  or  other  of  the  following  purposes: 

1.  To  aid  and  fortify  the  senses  of  sight  and  hearing — e.  g, 
pocket  microscope,  stethoscope,  etc. 

2.  To  view  the  interior  of  organs — e.  g.,  ophthalmoscope, 
oral  and  nasal  specula,  oesophagoscope,  laryngoscope,  cysto- 
scope,  proctoscope,  endoscope. 

3.  To  view  the  shadow  cast  by  foreign  bodies  and  solid 
organs — e.  g.,  the  a;-ray  machine.  To  determine  the  out- 
lines of  a  hollow  viscus  by  transillumination — e.g.,  gastro- 
diaphane. 

4.  To  obtain  the  secretions  and  contents  of  the  hollow 
viscera — e.  g.,  stomach  tube,  catheter,  etc. 

5.  To  determine  the  chemical  and  physical  nature  of  the 
secretions  and  body  fluids — e.  g.,  hsemoglobinometer,  hremo- 
cytometer,  cryoscope,  etc. 

6.  To  determine  the  calibre,  length,  and  position  of  hollow 
organs — e.  g.,  sounds  and  bougies. 

7.  To  determine  the  presence  of  foreign  bodies  in  th( 
hollow  organs — e.  g.,  the  vesical  sound,  oesophageal  sound 
etc. 

General  Considerations  on  Instruments. — All  instru- 
ments that  are  introduced  into  bodv  cavities  should  be  made 


THE  EXAMINER  21 

clean  by  boiling,  or,  if  this  is  not  possible,  by  immersion  in 
5  per  cent,  carbolic  acid  solution  for  fifteen  minutes.  In 
the  latter  case  they  should  be  washed  in  distilled  or  sterile 
water  just  before  they  are  used.  Instruments  should  always 
be  in  perfect  order,  and  should  be  tested  and  examined 
before  each  using.  Those  that  are  meant  to  be  passed  into 
cavities  should  be  perfectly  smooth  and  highly  polished, 
lest  they  abrade  or  tear  the  channels  through  which  they 
are  to  pass. 

The  modern  surgeon  must  cultivate  expertness  in  the  use  of 
all  instruments  and  in  the  interpretation  of  the  findings  ob- 
tained by  them.  It  is  as  necessary  for  the  diagnosis  of  brain 
tumor,  brain  abscess,  cerebral  compression,  or  sinus  throm- 
bosis, to  recognize  a  choked  disk,  as  it  is  to  make  out  axial 
deviation  and  shortening  in  fracture  of  the  long  bones.  A 
specialist  in  the  diseases  of  the  eye,  ear,  etc.,  is  not  always  at 
hand.  That  surgeon  will  make  the  best  diagnosis  whose 
skill  in  the  handling  of  instruments  and  whose  training  in 
the  interpretation  of  their  findings  are  the  most  perfect. 

Most  of  the  instruments  detailed  above  are  so  well  known 
that  little  need  be  said  in  description  or  explanation  of  them. 

Cystoscope. — Of  cystoscopes  there  are  several  models.  The 
author  personally  feels  that  the  expert  in  cystoscopy  should 
be  equally  familiar  in  the  use  of  one  example  of  each  type 
of  the  instrument,  viz.,  in  the  direct-vision  cystoscopes— 
e.  g.,  Kelly's  tubes;  the  direct  telescopic  cystoscopes,  and  the 
indirect  (prism)  telescopic  cystoscopes. 

The  field  of  vision  of  the  direct  cystoscopes  is  larger  and 
clearer  than  that  of  the  indirect,  but  the  former  are  of  little 
value  in  those  patients  who  have  prostatic  enlargement  and 
a  retroprostatic  basin  in  the  bladder.  For  general  use  the 
author  would  recommend  the  indirect  catheterizing  cystoscope 
of  Nitze. 

Roentgen  Machine. — The  Roentgen  machine  is  daily  be- 
coming more  essential  to  the  diagnostician;  not  only  for 
the  information  it  affords  of  the  position  of  fractured  or  dis- 
located bones,  but  also  for  the  detection  of  foreign  bodies, 
neoplasms,  rarefying  and  sclerosing  conditions  of  the  bones, 
etc.  For  purposes  of  diagnosis  a  medium  hard  tube  with 
self -regulating  tension  is  the  best. 


22  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

(Esophagoscope. — The  oesophagoscope  has  only  recently 
found  a  general  use.  It  is  of  decided  value  in  the  examina- 
tion of  the  oesophagus  and  cardiac  end  of  the  stomach.  The 
diagnosis  of  diverticula,  ulcerations  (benign  and  malignant), 
spasms,  and  stenosis  of  the  oesophagus  will  be  rendered  more 
certain  when  sufficient  expertness  in  the  use  of  this  instru- 
ment shall  have  been  gained.  The  best  type  of  instrument 
is  the  straight  tube  with  a  light  carrier  introduced  down  to 
the  bottom  of  the  tube. 

Beckman's  Cryoscope. — The  modern  surgeon  desires  to 
know  not  only  the  existence  and  nature  of  diseased  processes 
in  the  kidneys,  but  also  the  separate  and  combined  func- 
tionating power  of  these  organs.  One  of  the  best  methods 
of  determining  the  latter  is  by  ascertaining  the  freezing  point 
of  the  urine  and  blood.  The  freezing  point  of  a  liquid 
depends  upon  the  number  of  molecules  it  holds  in  solution; 
the  greater  the  molecular  concentration  of  a  fluid  as  com- 
pared with  that  of  distilled  water,  the  lower  will  be  its  freez- 
ing point.  With  insufficient  kidney  action  the  concentration 
of  the  blood  rises,  while  that  of  the  urine  falls;  under  these 
conditions  the  freezing  point  of  the  blood  will  fall  below  its 
normal  point,  while  that  of  the  urine  will  rise.  Normal 
blood  freezes  at  0.56°  to  0.59°  below  distilled  water;  with 
insufficient  kidney  action  it  freezes  at  0.60°  or  more  below 
distilled  w^ater.  Similarly  normal  urine  freezes  at  1°  to  2° 
below  distilled  water;  with  insufficient  kidney  action  the 
freezing  point  rises  to  0.8°  or  0.9°  or  more  below  distilled 
water.  The  freezing  point  of  the  blood  and  urine  is  ascer- 
tained by  the  Beckman  cryoscope  which  has  recently  been 
introduced  from  the  physical  into  the  medical  laboratory 
by  Koranyi  of  Budapest.  (For  further  details  of  this  instru- 
ment and  the  technique  of  its  use,  see  Diseases  of  Kidneys, 
p.  377.) 

Hsemoglobinometer  of  Dare. — The  hsemoglobinometer  of 
Dare  is  used  by  us  in  hospital  and  private  practice.  It 
is  simple  in  construction,  small  in  bulk,  and  gives  suffi- 
ciently accurate  results. 

For  counting  the  number  of  red  and  white  blood  cells  we 
use  the  Thoma-Zeiss  hpemocytometer.  (For  technique,  see 
Anpemia  and  I^eukocytosis,  p.  35.) 


CHAPTER    11. 

THE  CLINICAL  SIGNIFICANCE  OF  GENERAL  SYMPTOMS 
IN  SURGICAL  DISEASES. 

In  this  chapter  will  be  considered  the  clinical  significance 
of  the  more  important  constitutional  and  physical  mani- 
festations of  acute  and  chronic  surgical  diseases.  Clinical 
evidences  of  disease  afforded  by  the  urine,  gastric  juice,  and 
excreta  will  be  considered  in  the  chapters  dealing  with  dis- 
eases of  the  kidneys,  stomach,  and  intestines. 

The  symptoms  that  especially  demand  attention  here  are 
cachexia,  emaciation,  jaundice,  pain,  fever,  pulse  rate,  res- 
piration rate,  general  gastrointestinal  disturbances,  anoemia, 
leukocytosis. 

Cachexia. — Cachexia  evidenced  by  a  dirty  (yellowish) 
pallor  of  the  skin  is  associated  with  the  later  stages  of 
secondary  anaemia  and  accompanies  those  diseases — e.  g., 
carcinoma,  phthisis,  syphilis,  chronic  septicoemia,  etc. — that 
give  rise  to  this  condition.  It  is  not  an  exclusive  nor  an 
invariable  accompaniment  of  malignant  disease. 

Emaciation. — Emaciation  testifies  to  disturbances  in 
metabolism,  either  in  a  faulty  assimilation  of  food  or  in 
increased  tissue  waste.  Excessive  tissue  destruction  can  be 
determined  by  comparing  the  total  nitrogen  ingested  with 
the  total  nitrogen  eliminated  in  the  urine  and  feces  (the  lat- 
ter can  best  be  determined  by  the  Kjeldahl  apparatus). 

Jaundice. — Jaundice,  a  yellowish  discoloration  of  the 
skin  and  mucous  membrane,  is  due  to  absorption  into  the 
blood  of  the  coloring  matters  of  the  bile  or  derivatives  of  it. 
(The  urine  becomes  very  high  colored;  the  stools  may  or 
may  not  be  whitish  in  color.) 

Two  forms  of  icterus  are  recognized :  the  obstructive  and 
the  haemohepatogenous. 

The  former  is  due  to  an  interference  with  the  passage  of 
the  bile  into  the  duodenum,  and  the  latter  to  an  excessive 


24  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 

destruction  of  red  blood  cells  in  the  liver.  The  haniioglobin 
which  is  set  free  by  the  disorganization  of  the  red  cells  is 
converted  into  bilirubin,  and,  being  secreted  into  the  finer 
hepatic  ducts  in  larger  amounts  than  can  be  readily  carried 
away,  part  of  it  is  resorbed  into  the  circulation  and  carried 
to  the  tissues,  which  it  stains.  The  excessive  destruction  of 
red  blood  cells  in  the  liver,  giving  rise  to  hsemohepatog- 
enous  jaundice,  occurs  after  the  administration  of  certain 
poisons — e.g.,  ether,  chloroform,' phosphorus,  etc.;  in  some 
of  the  infectious  diseases,  septicaemia,  pneumonia,  acute 
yellow  atrophy  of  the  liver,  etc.  The  intensity  and  con- 
stancy of  the  jaundice  depends  upon  the  extent  and  dura- 
tion of  the  haemolysis. 

The  impediment  to  the  free  passage  of  bile  into  the  duo- 
denum (obstructive  jaundice)  may  be  located  anywhere, 
from  the  finest  bile-capillaries  to  the  orifice  of  the  common 
bile-duct  at  the  papilla  of  Vater.  The  causes  may,  therefore, 
be  divided  into  the  intrahepatic  and  extrahepatic.  In  the  for- 
mer the  obstruction  may  involve  all  the  bile-ducts  or  be  limited 
to  the  ducts  of  larger  or  smaller  areas  of  the  liver,  and  the 
intensity  of  the  jaundice  will  very  naturally  vary  with  the 
extent  of  the  involvement.  Thus  the  swelling  and  occlusion 
of  the  biliary  capillaries  in  the  liver  resulting  from  a  gen- 
eral or  diffuse  cholangitis  will  result  in  deep  jaundice; 
whereas  a  cyst  or  carcinoma  or  abscess  giving  rise  to  local 
inflammation  of  the  bile-ducts  (circumscribed  cholangitis) 
will  be  accompanied  by  little  or  no  jaundice.  In  the 
extrahepatic  forms  of  obstructive  jaundice  the  impediment 
may  lie  within  the  ducts,  as  from  a  calculus,  or  stricture, 
or  neoplasm;  or  it  may  be  due  to  the  pressure  or  traction 
upon  the  ducts  by  a  neighboring  organ— e.  g.,  floating 
kidney  or  enlarged  head  of  the  pancreas  (from  neoplasm 
or  chronic  inflammation),  or  enlarged  gall-bladder  or  tumor 
of  pylorus,  or  tumor  or  abscess  of  the  liver,  etc.;  or  it  may 
be  due  to  kinking  of  the  ducts  by  the  contraction  of  sur- 
rounding adhesions.  The  grade  of  jaundice  varies  with  the 
extent  of  compression,  stenosis,  or  obliteration  of  the  ducts; 
its  constancy  varies  according  to  the  permanency  of  the  com- 
pressing, stenosing,  or  obliterating  factors.  With  obstruc- 
tion of  the  common  bile-ducts  by  calculus  the  gall-bladder 


GENERAL  SYMPTOMS  IN  SURGICAL   DISEASES      25 

is  usually  contracted,  the  icterus  varies  in  intensity,  the 
stools  being  at  times  brown,  again  white;  the  spleen  is  some- 
what enlarged,  and  there  is  a  history  of  colicky  pain  and 
intermittent  fever.  With  obturation  or  compression  of  the 
common  bile-ducts  by  tumor,  the  gall-bladder  is  enlarged 
and  distended,  the  jaundice  grows  constantly  deeper,  the 
stools  are  continuously  white,  there  is  no  history  of  colicky 
pain  or  fever,  and  the  spleen  is  not  enlarged.  These  points 
of  difference  are  designated  as  Courvoisier's  law,  and  their 
importance  in  differential  diagnosis  will  be  discussed  under 
Cholelithiasis.    (See  p.  315.) 

Pain. — This  is  a  subjective  symptom,  and  in  forming  an 
estimate  of  its  intensity  due  allowance  must  be  made  for 
the  character  of  the  individual.  People  of  stoical  character 
bear  pain,  even  of  severe  degree,  without  much  complaint; 
whereas,  others,  of  sensitive  nature,  magnify  its  severity. 
Each  individual  is  a  law  unto  himself,  as  to  how  intensely 
he  reacts  to  painful  sensations.  The  physician  must  by 
observation  and  experience  learn  to  estimate  how  much 
pain  a  patient  really  suffers. 

Pain  is  either  neuralgic  or  parenchymatous  in  its  origin; 
in  the  former  the  exciting  cause  acts  upon  the  trunk  of  a 
sensory  or  mixed  nerve  or  upon  the  sensory  centres.  In  the 
latter  the  irritating  factor  acts  upon  the  peripheral  sensory 
end  organs. 

Neuralgic  pain  is  absolutely  limited  to  the  area  supplied 
by  the  nerve  or  nerves  which  are  the  seat  of  irritation — e.  g., 
in  trigeminal  neuralgia  or  in  the  case  of  callus  or  scars  press- 
ing upon  sensory  nerves.  In  parenchymatous  pain  the 
affected  sensory  end  organs  may  belong  to  several  different 
spinal  nerves;  consequently  the  painful  area  is  not  limited 
to  the  region  of  distribution  of  one  spinal  nerve.  Neuralgic 
pain  is  limited  to  a  definite  anatomical  area;  parenchyma- 
tous pain  is  diffuse,  invading  the  region  of  distribution  of 
several  nerves.  Neuralgic  pains  are  more  intense  and  more 
transient  than  parenchymatous  pains.  The  latter  are  asso- 
ciated with  tenderness  over  the  affected  part;  whereas,  with 
neuralgic  pain  there  is  tenderness  directly  over  the  irritated 
nerve,  and  then  only  in  case  it  is  superficial  and  can  be 
compressed    against    a    solid    bony    structure.      Neuralgic 


26  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 

pain  is  due  to  inflammation  of  nerve  trunks,  new-growths 
of  nerve  trunks,  (neuroma  or  sarcoma),  or  pressure  on  nerve 
trunks  by  neighboring  neoplasm  (e.  g.,  scar,  calkis  or  exudate). 
A  frequent  error  in  diagnosis  arises  from  confounding  the 
irritation  of  the  sciatic  nerve  by  chronic  inflammation  (the 
common  form  of  sciatica)  with  the  sciatic  pain  which  is  due 
to  compression  and  irritation  of  the  sciatic  nerve  by  small 
pelvic  tumors.  Parenchymatous  pain  is  due  to  disease  or 
injury  of  any  part. 

Character  of  Pain. — Neuralgic  pains  are  usually  very  in- 
tense, transient,  sharp,  burning,  or  cutting;  there  are  local 
points  of  tenderness  over  the  superficial  nerves. 

Parenchymatous  pains  are  apt  to  be  less  intense  and  con- 
stant, and  are  either  sharp  and  cutting  or  dull  and  aching; 
there  is  tenderness  over  the  entire  painful  area. 

Colicky  pain  in  tubular  viscera  is  a  composite  one,  com- 
posed of  the  pain  produced  by  a  foreign  body,  kink,  or  con- 
striction which  obstructs  the  lumen  of  the  tube,  and  secondly 
of  the  pain  which  results  from  the  forcible  contractions  of 
the  tube  in  its  endeavors  to  overcome  the  obstruction.  The 
first  element  may  be  continuous,  sharp,  and  cutting— e.  g., 
when  a  stone  is  impacted  in  the  bile-ducts  or  ureters;  the 
second  element  is  sudden,  wave-like,  and  sharp,  and  sub- 
sides suddenly.  The  appendix,  gall-bladder,  and  kidneys 
are  frequently  the  seat  of  such  colicky  pains. 

Location  of  Pain. — The  pain  may  be  referred  to  the  area 
of  distribution  of  the  irritated  nerve  or  to  the  diseased  part. 
In  such  cases  the  site  of  the  pain  is  a  valuable  aid  in  diagnosis. 
Often,  however,  the  pain  is  referred  to  some  distant  region 
(radiate  pain) — e.  g.,  the  pain  in  the  knee-joint  from  hip 
disease,  the  pain  over  the  appendix  from  right  basal  pleurisy. 
Quincke^  has  formulated  these  radiate  pains  as  far  as  they 
are  known  and  established.  The  most  important  are:  tri- 
geminal pain  in  frontal-sinus  disease;  parietal  pain  in  dis- 
eases of  the  middle  ear  and  mastoid;  laryngeal  pain  in  prob- 
ing pulmonary  abscesses ;  pain  in  the  left  shoulder,  at  times  in 
the  right,  with  angina  pectoris ;  pain  in  the  lower  dorsal  region 
with  stomach  affections ;  pain  in  the  right  shoulder  and  back 

1  Zeitschr.  fiir  klin.  Med.,  1890,  Bd.  17. 


GENERAL  SYMPTOMS  IN  SURGICAL   DISEASES     27 

with  liver  and  gall-bladder  diseases;  pain  in  the  back,  blad- 
der, and  genitals  in  kidney  diseases;  epigastric  pain  in  endo- 
metritis; knee  pain  in  coxalgia;  right  iliac  pain  in  right  basal 
pleurisy;  left  iliac  pain  in  left  basal  pleurisy;  left  shoulder 
pain  in  diseases  of  spleen.  The  diagnostician  must  con- 
stantly be  on  his  guard  in  the  correct  interpretation  of  these 
radiate  pains.  He  must  be  conversant  with  them,  and  never 
neglect  to  examine  the  organ  from  which  the  pain  may 
radiate,  as  well  as  the  painful  region  itself.  Many  an  appen- 
dix is  removed  for  a  right  basal  pleurisy;  many  a  knee-joint 
accused  of  tuberculosis  when  the  hip  is  really  at  fault. 

In  addition  to  the  radiate  pain,  it  has  been  shown  by 
the  English  neurologist,  Head,  that  diseases  of  the  internal 
organs  are  usually  attended  by  a  hyperaesthesia  of  definite 
areas  of  the  skin.  The  areas  of  cutaneous  hyperaesthesia 
symptomatic  of  the  diseases  of  the  various  internal  organs 
have  been  accurately  mapped  out  by  Head,  and  he  considers 
them  valuable  aids  in  the  diagnosis  of  diseases  and  injuries 
of  these  parts.  They  often  correspond  to  the  regions  to 
which  the  pain  radiates,  as  described  above.  In  order  to 
determine  the  zones  of  cutaneous  hyperaesthesia,  a  blunt- 
pointed  instrument  should  be  passed  along  the  skin  from 
above  downward,  the  patient  being  instructed  to  say  when 
he  feels  the  pressure  of  the  instrument  most. 

The  hyperalgesic  skin  areas  in  diseases  of  the  internal 
viscera  are,  according  to  Head,  as  follows : 

Desckiption  of  Figs.  1  and  2. 

Zones  of  cutaneous  hypersesthesia  symptomatic  of  diseases  of  the  internal  organs. 
They  are  indicated  by  letters  and  subjacent  numerals  which  correspond  to  the  spinal- 
cord  segments  from  which  the  nerves  supplying  the  affected  portions  of  skin  are 
derived. 

Heart  diseases  :  Pain  and  hypersesthesia  in  zones  C3,  i>i,  D4. 

Tuberculous  lung  diseases  :  Pain  and  hypersesthesia  in  zones  Di — D-,,  especially  Do, 

A.  A- 
Diseases  of  oesophagus  :  Pain  and  hyperaesthesia,  especially  in  D^,  Dj,  Dg,. 
Diseases  of  mamma  :  Pain  and  hypersesthesia  in  D^,  D^. 
Diseases  of  stomach  :  Pain  and  hypersesthesia  in  X>o,  Dg,  -Do- 
Diseases  of  intestines,  pylorus,  and  colon  :  Pain  and  hypersesthesia  in  Dm,  Du,  A-.>- 
Diseases  of  liver  :  Pain  and  hypersesthesia  in  D7,  Bs,  Dci,  Dio. 
Diseases  of  kidney  and  ureter :  Pain  and  hyperesthesia  in  Djo,  Dn,  Li- 
Diseases  of  bladder :  Pain  and  hypersesthesia  in  &,  S3,  S4.- 
Diseases  of  testicle  and  ovary  :  Pain  and  hypersesthesia  in  Dm. 
Diseases  of  uterus  :  Pain  and  hypersesthesia  in  Djo,  Ai>  -D121  -Z-i- 
Diseases  of  cervix  :  Pain  and  hypersesthesia  in  Si,  So,  S'j,  S4. 


Fig.  1 


Fig.  2 


30 


GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 


The  diagrams  show  the  zones  of  skin  which  the  indicated 
spinal  segment  suppHes;  the  accompanying  tables  state  the 
particular  zones  that  are  affected  in  diseases  of  the  individual 
viscera. 

Pain,  Muscular  Rigidity,  and  Reflex  Spasm. — Wherever  there 
is   pain,  there  we  find  muscular  immobility  and  muscular 


Fig.  3 


Naso-frontal 
zone 


MaxiUar 
zone 

Naso-labial 
zone 


Middle  orbital 
zone 

Temporo-fvontal 
zone 


Fig.  4 


Middle  orbital 
zone 


Temporo-frontal 
zone 
Temporal  zone 


Lcderal  parietal 
zone 

Parietal  zone 


Occipital  zone 

Mamillary 
zone 

Hyoid  zone 


Upper  ) 

r  Laryngeal 

r  r     zone 

Lower  \ 


GENERAL   SYMPTOMS  IN   SURGICAL   DISEASES      31 

rigidity.  It  is  the  attempt  on  the  part  of  nature  to  afford 
protection  to  the  painful  part.  Such  muscular  rigidity  and 
reflex  muscular  spasm  are  often  the  earliest  signs  of  inflam- 
mation. Thus  the  rigidity  of  the  abdominal  wall  in  inflam- 
mations of  the  peritoneum.  (Rigidity  of  the  abdominal 
wall  is  best  elicited  by  watching  whether  it  moves  with 
respiration,  and  by  passing  the  finger-tips  gently  over  its  sur- 
face. Deep  palpation  excites  reflex  contraction  and  thus 
obscures  rigidity.  Note  that  the  rigidity  may  be  local  or 
general,  depending  upon  the  extent  of  involvement  of  the 
peritoneum.)  The  immobility  of  the  chest  in  inflammatory 
diseases  of  the  pleura  and  the  reflex  muscular  spasm  in  joint 
disease  are  other  instances  of  muscular  rigidity  attending 
painful   diseases. 

When  a  history  of  pain  is  elicited,  it  is  well  to  enquire 
whether  there  have  been  any  previous  attacks.  Such  a  his- 
tory is  of  importance  in  establishing  a  diagnosis  in  doubtful 
cases  of  cholelithiasis,  renal  calculus,   appendicitis,  etc. 

It  is  further  important  to  ascertain  whether  the  present 
attack  of  pain  is  or  is  not  similar  to  that  in  previous  attacks. 
Thus  the  patient  may  have  had  a  number  of  attacks  of  sharp 
pain  in  the  gall-bladder  or  appendix  or  in  the  stomach,  etc., 
but  in  the  present  attack  tlie  pain  is  of  a  tearing  character, 
is  much  more  intense  and  accompanied  by  prostration.    We 


Description  of  Figs  3  and  4. 

Head  and  neck  zones  : 

Nasofrontal  zone  is  affected  by  diseased  conditions  of  the  eyes,  nose,  and  upper 
incisor  teeth. 

Middle  orbital  zone  ;  Affected  by  hypermetropia. 

Temporofrontal  zone  :  Affected  by  diseased  conditions  of  ear  and  heart. 

Temporal  zone  :  Affected  by  glaucoma. 

Lateral  parietal  zone  :  Affected  by  middle-ear  disease. 

Parietal  zone  :  Affected  by  ear  and  stomach  diseases. 

Occipital  zone  :  Affected  by  diseased  conditions  of  posterior  one-half  of  larynx, 
and  some  of  the  intestines. 
,  Maxillary  zone  :  Affected  by  diseases  of  iris  and  cornea. 

Mandibular  zone  :  Affected  by  diseases  of  upper  molars. 

Nasolabial  zone  :  Affected  by  diseases  of  nose  and  tooth  pulp. 

Mental  zone  :  Affected  by  diseases  of  incisors  and  bicuspid  teeth. 

Hyoid  zone  :  Affected  by  diseases  of  tonsils,  tongue,  and  lower  molars. 

Upper  laryngeal  zone  :  Affected  by  diseases  of  dorsum  of  tongue  and  wisdom  teeth. 

Lower  laryngeal  zone  :  Affected  by  diseases  of  larynx. 

According  to  Head,  diseased  conditions  of  the  serous  membranes  are  not  attended 
with  hypenesthetic  skin  zones. 


32  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 

would  infer  from  such  a  history  that  a  rupture  of  the  viscus 
had  taken  place  during  the  present  seizure. 

The  relation  of  pain  to  other  bodily  functions,  to  the 
ingestion  of  food,  is  also  very  important  from  a  diagnostic 
standpoint.  Pain  over  the  pylorus  immediately  after  the 
ingestion  of  food  suggests  gastric  ulcer;  pain  in  the  pyloric 
region  one  or  two  hours  after  a  meal,  a  duodenal  ulcer;  pain 
on  defecation,  a  fissure  in  ano,  or  an  ulcer  of  the  rectum; 
pain  before  and  during  urination,  cystitis;  pain  after  urina- 
tion, disease  of  the  neck  of  the  bladder.  Tuberculosis  and 
calculous  diseases  of  the  kidney  frequently  give  as  their  first 
manifestation  increased  frequency  and  painful  urination. 
Cholecystitic  pain  is  apt  to  become  worse  two  to  three  hours 
after  a  hearty  meal. 

The  influence  of  bodily  movement  on  pain  is  often  a  clue 
to  diagnosis.  Thus  the  pain  of  stone  is  made  worse  by  walk- 
ing, jumping,  going  up  and  down  stairs.  Pleuritic  pain 
becomes  worse  on  deep  inspiration;  peritonitic  pain  by 
peristalsis. 

As  said  at  the  outset,  pain  is  a  purely  subjective  symp- 
tom. Hysterical  patients  may  complain  of  intense  pain  and 
yet  there  is  no  cause  therefor.  It  must  however  be  strongly 
advised  never  to  consider  pain  as  hysterical  or  as  trivial 
until  repeated  careful  physical  examinations  have  revealed 
no  underlying  cause  therefor. 

Fever;  Pulse  Rate;  Respiration  Rate. — The  normal 
bodily  temperature  of  an  adult  individual  is  98.6°,  the  pulse 
rate  70  to  80  to  the  minute,  and  the  respiration  rate  18  to  20 
to  the  minute.  In  all  cases  in  which  variations  from  the  normal 
are  suspected  the  temperatures  should  be  taken  per  rectum 
every  three  or  four  hours  and  recorded  on  a  chart,  the  pulse 
rate  and  respiration  rate  being  coincidently  noted  and  recorded. 

An  increased  bodily  temperature  may  follow  (1)  upon  dis- 
turbances in  the  central  nervous  system — e.  g.,  after  great 
fright  or  excitement,  after  epileptic  seizures,  injuries  of  the 
spinal  cord,  etc. ;  and  (2)  upon  the  resorption  into  the  general 
circulation  of  deleterious  bodies  such  as  fibrin  ferment  and 
the  toxins  of  bacterial  life.  Increased  temperatures  from  the 
latter  cause  may  be  of  a  continuously  high  type  with  fluctua- 
tions of  half  a  degree,  in  which  case  it  indicates  a  continuous 


GENERAL  SYMPTOMS  IN  SURGICAL  DISEASES      33 

resorption  of  deleterious  bodies.  The  height  will  depend  upon 
the  virulency  of  the  toxins  and  upon  the  amount  and  rapidity 
of  their  absorption,  which  latter  in  turn  depends  upon  the 
tension  under  which  the  toxic  products  are  confined  in  the 
tissues.  Such  continuous  high  temperatures  accompany  sim- 
ple or  suppurative  inflammation.  With  the  onset  of  the  dis- 
ease there  is  usually  a  distinct  chill  or  chilly  sensation. 

The  elevated  temperature  may  be  of  an  intermittent  or 
remittent  type,  with  marked  fluctuations.  With  each  rise 
there  may  be  another  chill  or  chilhness.  Such  intermittent 
or  markedly  remittent  temperatures  indicate  an  extension 
of  the  inflammation  with  new  absorption  of  toxins.  They 
occur  with  advancing  inflammations  like  erysipelas,  and 
in  extending  suppurative  inflammations,  especially  those  of 
the  vascular  system,  for  in  these  latter  cases  infected  em^boli 
from  the  primary  seat  of  disease  are  being  constantly  dis- 
lodged into  the  blood  stream  and  carried  to  distant  organs, 
where  they  set  up  fresh  suppurations  (metastatic).  The  fluc- 
tuations of  temperature  have  no  regularity.  They  may  occur 
daily,  or  several  times  daily,  or  at  intervals  of  several  days. 

The  height  of  the  temperature  is  usually  proportionate 
to  the  amount  of  resorption  of  toxins.  This  is  in  turn  de- 
pendent on  the  tension  under  which  the  toxins  are  confined 
in  the  tissues.  A  small  abscess  under  high  tension — e.  g.,  in 
the  neck  under  the  deep  fascia  (angina  Ludovici) — may  give 
rise  to  high  temperatures,  whereas  a  large  abscess  in  loose 
cellular  tissue  may  occasion  only  moderate  febrile  elevations. 

Temperature  and  Pulse  Rate  in  Inflammations  of  Tubu- 
lar Abdominal  Viscera. — High  temperatures  accompany- 
ing suppurations  in  tubular  viscera  whose  orifice  of  exit  has 
become  closed — e.  g.,  appendix,  gall-bladder,  Fallopian  tube 
— indicate  that  the  inflammatory  products  within  these  organs 
are  under  considerable  tension.  Low  temperatures  with 
rapid  pulse  rate  in  inflammatory  conditions  of  such  tubular 
viscera  point  to  gangrene  of  the  afi^ected  organ.  The  tem- 
perature is  low  because,  on  account  of  the  paralysis  of  the 
inflamed  part  which  results  from  the  gangrene,  the  tension 
of  the  inflammatory  products  within  it  cannot  rise  very  high. 
The  pulse  rate,  however,  is  rapid  and  out  of  all  proportion 
to  the  temperature.     In  both  these  conditions  operation  is 

3 


34  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 

imperatively  indicated,  lest  perforation  with  extravasation 
of  septic  material  into  the  peritoneal  cavity  occur.  Again 
the  onset  may  have  been  very  acute,  with  chill  and  high 
temperature  and  proportionally  rapid  pulse.  Suddenly  the 
temperature  falls  to  normal  or  near  the  normal,  but  the 
general  condition  of  the  patient  is  not  improved  or  it  even 
becomes  worse.  This  indicates  a  sudden  lowering  of  ten- 
sion from  gangrene  or  perforation,  and  operation  becomes 
imperative. 

A  rise  in  bodily  temperature  is  usually  accompanied  by  a 
coincident  proportionate  rise  in  pulse  and  respiration  rate. 
In  suppurative  or  gangrenous  inflammations  of  the  peri- 
toneum, and  in  peritoneal  septicaemia,  the  pulse  rate  rises 
out  of  all  proportion  to  the  temperature.  Even  with  severe 
suppurative  inflammations  of  the  peritoneum,  the  tempera- 
ture may  be  low  but  the  pulse  rate  is  high.  The  high  pulse 
rate  and  low  temperatures  are  especially  characteristic  of 
peritoneal  septicaemia.  By  Friedlander  this  has  been  attrib- 
uted to  vagus  disturbance. 

The  respiration  rate  is  increased  out  of  proportion  to  the 
temperature  and  pulse  rate  in  all  diseases  of  the  respiratory 
tract. 

To  sum  up  the  foregoing  remarks: 

Continuous  high  temperature,  high  pulse  rate,  and  high 
respiration  rate  are  indicative  of  continuous  toxin  resorp- 
tion, from  simple  or  suppurative  inflammation. 

Fluctuating,  intermittent,  or  remittent  temperatures  indi- 
cate an  extension  of  the  original  inflammation  or  a  fresh 
injection  of  toxins  or  bacteria  into  the  systemic  circulation. 
Each  extension  or  fresh  injection  may  be  accompanied  by  a 
chill. 

The  height  of  the  temperature  depends  upon  the  rapidity 
and  amount  of  resorption,  which  in  turn  is  dependent  upon 
the  tension  under  which  the  inflammatory  products  are 
confined.  Paralysis  of  a  viscus  or  gangrene  of  its  walls 
results  in  a  diminution  of  the  inflammatory  tension,  the 
rapidity  of  resorption  is  consequently  lessened,  and  the  tem- 
peratures are  apt  to  decline.  The  pulse  rate,  however,  re- 
mains rapid  because  the  toxaemia  continues,  and  is  even 
increased  by  the  gangrene  or  paralysis  of  the  affected  part. 


GENERAL  SYMPTOMS  IN  SURGICAL  DISEASES      35 

High  temperatures  indicating  a  high  tension,  followed  by 
a  sudden  decline  of  temperature  with  no  coincident  im- 
provement in  the  general  condition,  point  to  gangrene  or 
paralysis  of  the  viscus. 

Temperatures  in  themselves  are  no  guide  to  the  nature, 
extent,  or  severity  of  the  inflammation.  The  pulse  rate, 
the  respiration  rate,  and  the  general  condition  of  the  patient, 
together  with  the  clinical  history  of  the  present  illness  must 
always  be  considered  in  conjunction  with  the  temperature. 
Peritoneal  septicaemia  is  regularly  attended  with  low  tem- 
peratures, but  high  pulse  and  respiration  rate. 

A  subnormal  bodily  temperature  occurs  chiefly  after 
exposure  to  intense  cold,  at  the  critical  period  of  some  acute 
febrile  diseases,  e.  g.,  pneumonia,  in  conditions  of  collapse, 
after  profuse  hemorrhage,  and  in  chronic  exhaustive  diseases, 
as  the  final  stages  of  tuberculosis  and  carcinoma. 

The  fall  of  temperature  that  accompanies  collapse  is 
attended  with  a  coincident  increase  in  the  rapidity  and  fee- 
bleness of  the  pulse,  which  latter  signs  distinguish  this  con- 
dition from  the  critical  period  of  febrile  diseases,  for  in  this 
latter  condition  the  pulse  becomes  slower  and  its  quality 
remains  good.  It  is  to  be  noted  that  collapse  may  be  excited 
reflexly  by  severe  injuries  or  by  mental  emotions,  or  it  may 
be  occasioned  by  poisons,  of  which  those  that  are  elaborated 
by  bacterial  life  and  development  are  especially  important. 
This  accounts  for  the  collapse  that  sometimes  attends  the 
acute  bacterial  diseases. 

Anaemia,  Leukocytosis.  Method  of  Examination  of  the 
Blood. — The  determination  of  the  haemoglobin  percentage 
of  the  blood  and  the  ascertainment  of  the  number  and  char- 
acter of  the  red  and  white  blood  cells  are  necessary  for  the 
diagnosis  of  essential  blood  diseases.  They  also  aid  in  the 
detection  of  those  primary  organic  diseases  which  occasion 
early  changes  in  the  blood,  and  they  shed  light  on  the  nature 
of  certain  inflammatory  processes. 

The  haemoglobin  percentage  is  estimated  by  the  Dare 
hsemoglobinometer.  The  red  and  white  blood  cells  are 
counted  with  the  Thoma-Zeiss  haemocytometer.  This  latter 
apparatus  consists  of  two  parts :  a  glass  graduated  capillary 
tube  with  a  bulbous  enlargement  near  one  end  that  serves  for 


36  GENERAL   CONSIDERATIONS  ON   DIAGNOSIS 

drawing  up  and  diluting  the  blood,  and  a  counting  chamber 
which  is  mounted  on  a  glass  slide.  The  ear  or  finger-tip  is 
pricked  and  the  blood  is  drawn  up  in  the  capillary  tube  to 
the  mark  0.5  c.c.  or  1  c.c;  the  tip  of  the  tube  is  wiped  off 
and  normal  saline  solution  is  then  drawn  up  into  the  tube 
and  bulb  to  the  mark  101,  thus  diluting  the  blood  two  hun- 
dred or  one  hundred  times,  depending  on  whether  we  have 
drawn  up  0.5  or  1  c.c.  of  blood  in  the  capillary  tube.  The 
combined  saline  solution  and  blood  in  the  bulb  are  well 
mixed  by  shaking.  The  fluid  in  the  capillary  tube  is 
then  expelled  and  a  drop  from  the  bulbous  mixing  chamber 
is  put  into  the  counting  chamber.  The  counting  chamber 
is  0.1  mm.  deep;  its  floor  is  divided  into  microscopic  quad- 
rates of  ^^0^  c.mm.  capacity,  which  are  grouped  in  squares 
of  sixteens  by  double  dark  dividing  lines.  The  counting 
chamber  is  now  covered  with  a  cover-glass,  care  being 
taken  to  expel  the  air  bubbles  between  them  and  to  pre- 
vent overflowing  of  the  mixture  into  the  trough  around  the 
chamber.  A  number  of  the  larger  squares  are  counted  and 
if  the  total  number  of  red  cells  they  contain  is  divided  by 
the  number  of  quadrates  counted,  the  average  contents  of  a 
quadrate  will  be  obtained.  This  is  then  multiplied  by 
400,000  or  800,000,  depending  upon  whether  the  blood  has 
been  diluted  100  or  200  times,  and  the  result  indicates  the 
number  of  red  blood  cells  in  a  c.mm.  of  blood.  The  count- 
ing of  the  white  blood  cells  is  done  in  exactly  the  same 
way;  the  blood  is,  however,  only  diluted  ten  times.  The 
dilution  is  made  with  a  1  per  cent,  acetic  acid  solution; 
this  takes  away  the  color  of  the  red  blood  cells  by  dissolv- 
ing out  their  hsemoglobin,  and  so  renders  counting  of  the 
leukocytes  more  easy.  The  average  number  of  leukocytes 
in  each  small  square  is  of  course  only  multiplied  by  40,000 
or  80,000,  for  the  dilution  is  only  one-tenth  that  used  in 
counting  the  red  cells. 

In  a  healthy  individual  the  red  cells  number  5,000,000. 
In  chlorosis  the  number  is  not  materially  diminished;  in 
anaemia  it  is.  The  number  of  white  blood  cells  in  a  healthy 
individual  is  5000  to  8000;  an  increased  number  (hyper- 
leukocytosis)  occurs  normally  during  digestion  of  proteids; 
in  some  of  the  infectious  diseases  and  with  cachexia  there 


GEXERAL   SYMPTOMS  IX  SURGICAL   DISEASES      37 

is  likewise  an  increased  number  of  leukocytes  (r.  g.,  of  car- 
cinoma, see  l)elow).  i\.n  increase  over  50,000  warrants  the 
diagnosis  of  leukaemia. 

For  staining  the  blood  corpuscles,  a  drop  of  blood  is 
placed  on  a  perfectly  clean,  dry  cover-slip;  this  is  placed 
upon  a  second  cover-slip,  and  after  a  second  or  two  the 
cover-slips  are  drawn  apart  by  a  rapid  gliding  action,  and 
the  thin  films  on  their  surface  allowed  to  dry  in  the  air. 
The  Jenner  stain,  consisting  of  methylene  blue  and  eosin 
dissolved  in  pure  methyl  alcohol,  is  employed  for  staining 
purposes.  The  cover-slip  is  floated,  film  downward,  in  the 
stain  for  one  or  two  minutes;  it  is  then  thoroughly  washed 
in  distilled  water,  dried,  and  mounted  in  Canada  balsam. 
Under  the  microscope,  the  following  forms  of  red  cells  may 
be  distinguished: 

1.  Normal  red  cells. 

2.  Very  large  (macrocytes)  or  very  small  (microcytes) 
red  cells. 

In  the  severe  ana?mias  are  found: 

3.  Irregular  form  red  cells  (poikilocytes),  or 

4.  Degenerated  red  cells  with  nucleus  and  granulated 
protoplasm  (normoblasts,  microblasts,  and  megaloblasts), 
and  the  following  forms  of  white  blood  cells : 

1.  Lymphocytes,  with  round  nucleus  and  small  body.  They 
originate  in  the  lymph  glands,  and  represent  the  leukocytes, 
which  are  chiefly  increased  in  number  in  lymphatic  leukaemia. 

2.  Mononuclear  leukocytes,  considerably  larger  than  pre- 
ceding, with  ovoid  nucleus  and  large  cell  body.  From  these 
develop  the 

3.  Polynuclear  leukocytes,  which  are  large,  irregular  in 
form,  finely  granular  and  possess  a  lobulated  nucleus  or  as 
many  as  four  nuclei.  This  variety  forms  70  to  75  per  cent, 
of  the  leukocytes  in  normal  blood,  and  it  is  these  cells  that 
.are  mainly  increased  in  hyperleukocytosis,  their  number 
rising  to  80  or  85  per  cent,  of  the  total  number  of  leuko- 
cytes. The  last  two  varieties  are  the  ones  which  are  chiefly 
increased  in  splenic  and  myelogenous  leukaemia. 

Ehrlich  divides  the  leukocytes  into  three  groups,  accord- 
ing to  the  size  and  the  staining  qualities  of  the  granules 
found  in  the  cytoplasm: 


38  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

1.  The  eosinophilic  cells:  large,  round,  granular  bodies 
with  granules  staining  deeply  with  eosiii  and  other  acid  dyes. 
They  come  from  the  medulla  of  the  bones,  and  normally 
form  1  to  3  per  cent,  of  the  leukocytes  of  the  blood.  Their 
presence  in  considerable  number  points  to  medullary  in- 
volvement. 

2.  The  basophilic  cells :  granules  staining  palely  with  basic 
dyes,  and  forming  ^  to  1  per  cent,  of  leukocytes  in  normal 
blood. 

3.  The  neutrophilic  cells:  granules  staining  only  with 
neutral  dyes. 

Anaemia. — By  this  is  designated  a  pallor  of  the  skin  and 
mucous  membranes  due  to  diminished  coloring  matter 
(haemoglobin)  in  the  blood  (oligochromia) .  As  a  pallid 
color  of  the  skin  and  mucous  membranes  may  occur  in 
completely  healthy  individuals,  it  is  essential  in  every  case 
to  count  the  number  of  the  red  blood  cells  and  estimate  the 
haemoglobin  percentage  before  one  assumes  the  existence  of 
an  anaemic  state.  A  pallid  color  with  normal  number  of  red 
cells  and  haemoglobin  percentage  is  found  in  the  early  stages 
of  stomach  diseases,  heart  diseases,  phthisis,  and  cachexia. 
In  their  advanced  stages  these  diseases  give  rise  to  a  secondary 
anaemia  in  which  the  destruction  of  haemoglobin  exceeds  the 
loss  of  red  blood  cells. 

In  the  early  stages  of  cancer  of  the  internal  viscera,  before 
a  tumor  is  palpable,  a  marked  anaemia  in  conjunction  with 
other  data,  which  in  themselves  are  insufficient  to  warrant 
a  diagnosis  of  malignant  disease,  furnishes  strong  presump- 
tive evidence  of  this  malady.  Thus  in  chronic  gastric  dis- 
ease a  marked  anaemia,  together  with  an  absence  of  free 
hydrochloric  acid  and  the  presence  of  lactic  acid  in  the  gas- 
tric contents,  is  strongly  suggestive  of  a  carcinoma  of  this 
organ.  But  only  in  the  light  of  "additional  confirmation" 
is  an  anaemia  to  be  considered  important  in  the  early  diag- 
nosis of  malignant  new-growth. 

In  conditions  of  severe  anaemia  the  administration  of  a 
general  anaesthetic  for  surgical  purposes  may  be  followed  by 
the  most  serious  consequences.  Mikulicz,  Da  Costa,  Kal- 
teyer,  Cabot,  and  others  have  found  that  the  administration 
of  a  general  anaesthetic  results  in  a  marked  destruction  of 


GENERAL   SYMPTOMS  IN  SURGICAL  DISEASES      39 

red  blood  cells  and  a  corresponding  reduction  in  the  per- 
centage of  haemoglobin.  In  patients  who  have  a  low 
haemoglobin  percentage  the  administration  of  a  general 
anaesthetic  may  so  much  further  reduce  the  haemoglobin 
that  the  remaining  amount  will  be  absolutely  insufficient  to 
carry  on  the  oxygen  function  of  the  blood,  and  death  will 
necessarily  follow.  The  importance  of  ascertaining  the 
haemoglobin  percentage  prior  to  the  administration  of  a 
general  anaesthetic  is  thus  very  evident;  it  should  be  a  part 
of  our  routine  examination  just  as  is  the  analysis  of  the 
urine.  Mikulicz  advises  against  the  administration  of  a 
general  anaesthetic  when  the  haemoglobin  is  below  30  per 
cent.;  other  investigators  place  the  limit  of  safety  at  40  per 
cent. 

Leukocytosis. — The  number  of  leukocytes  in  the  blood 
is  often  of  considerable  diagnostic  importance.  For  this 
purpose  the  count  must  be  made  repeatedly  and  systematic- 
ally, for  only  in  this  way  can  a  rise  or  fall  or  stationary  con- 
dition of  the  number  of  white  cells  be  determined.  A  single 
count  is  of  very  little  clinical  value;  only  the  course  of  the 
leukocyte  count  enables  us  to  draw  any  valuable  conclu- 
sions. It  is  to  be  noted  that  in  young  subjects  the  number 
of  leukocytes,  even  in  health,  fluctuates  considerably,  and 
furthermore  that  a  physiological  hyperleukocytosis  (to 
10,000  or  20,000)  occurs  during  proteid  digestion. 

From  the  results  of  the  investigations  of  a  number  of 
observers  (Cabot,  Reich,  Mikulicz,  etc.)  the  following  con- 
clusions may  be  drawn: 

1.  Leukocyte  Count  in  Inflammation  of  Soft  Parts. — With" 
inflammations  in  the  soft  parts  (cellular  tissues,  etc.)  a  leuko- 
cyte count  of  20,000  or  over  remaining  constant  or  increasing 
for  three  or  four  days  speaks  strongly  in  favor  of  acute  pro- 
gressive abscess  formation.  With  latent  abscess  or  chronic 
•abscess  there  is  no  hyperleukocytosis. 

The  hyperleukocytosis  which  goes  with  acute  abscess  fre- 
quently aids  in  the  diagnosis  of  a  purulent  collection  when 
other  clinical  evidences  are  wanting  or  obscure.  It  helps 
further  to  differentiate  between  an  acute,  inflammatory,  non- 
purulent exudate  and  an  abscess;  its  presence  warrants  an 
incision,  even  though  other  clinical  evidences  of  pus  are 


40  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 

wanting.  A  high  leukocyte  count  (20,000  to  30,000)  three 
days  after  the  incision  of  an  acute  abscess  speaks  in  favor 
of  pus  retention  or  of  another  abscess,  even  though  the  tem- 
perature is  low;  whereas  a  low  count,  even  with  high  tem- 
perature, speaks  against  such  a  possibility.  Further,  if  with 
an  acute  inflammatory  exudate  with  high  temperature  the 
leukocyte  count  falls  suddenly  from  high  numbers,  there  is 
every  probability  of  resolution  without  pus  formation. 

2.  Leukoc3rte  Count  in  Inflammation  of  Bones. — Acute  swp- 
furation  of  the  bones  is  attended  with  high  leukocytosis  (over 
20,000),  even  higher  than  in  suppurations  of  the  soft  parts. 
In  the  very  early  stages  of  acute  infectious  osteomyelitis 
the  hyperleukocytosis  is  not  marked  enough  to  distinguish 
this  malady  from  acute  rheumatism,  neuralgia,  or  growing 
pains.  This  is  especially  the  case  in  children,  who  are  the 
most  frequent  sufferers  from  this  affection,  and  who  nor- 
mally have  a  widely  fluctuating  number  of  leukocytes. 

Because  of  the  slightly  increased  leukocytosis  attending 
acute  infectious  osteomyelitis,  we  cannot  rely  upon  the 
number  of  the  leukocytes  for  the  differentiation  of  this 
malady  from  typhoid  fever,  which  it  often  closely  resembles, 
and  which  is  always  accompanied  with  a  low  leukocyte 
count. 

Latent  bone  abscess,  chronic  bone  suppuratioji,  bone  necro- 
sis do  not  alter  the  number  of  white  blood  cells  sufficiently 
to  aid  us  in  their  diagnosis. 

After  operation  a  falling  leukocyte  count,  even  in  the 
face  of  a  high  temperature,  points  to  a  recrudescence  of  the 
inflammation,  and  vice  versa. 

3.  Leukocjrte  Count  in  Inflammations  of  Serous  Membranes, 
— In  meningitis  Cabot  thinks  hyperleukocytosis  is  the  rule. 
The  leukocyte  count  does  not  aid  us  in  the  differential  diag- 
nosis between  meningitis,  brain  abscess,  cerebral  hemor- 
rhage, epidemic  cerebrospinal  meningitis,  and  pneumonia. 
A  low  white  blood  count  in  this  disease  is  of  bad  prognostic 
import. 

In  pleurisy  a  high  leukocyte  count  in  acute  cases  speaks 
in  favor  of  pus.  Serous  exudates  ordinarily  do  not  cause 
hyperleukocytosis.  In  chronic  empyemata  there  is  no  hyper- 
leukocytosis. 


GE^rERAL   SYMPTOMS   IX   SURGICAL   DISEASES      41 

It  is  to  be  noted  that  the  exploratory  needle  is  a  much 
more  reliable  guide  to  differentiate  between  serous  and 
purulent  effusions. 

4.  In  Intra-abdominal  Conditions,  (a)  Intestinal  Obstruction. 
— The  majority  of  observers  report  no  hyperleukocytosis. 
Bloodgood  would  draw  conclusions  as  to  the  condition  of 
the  bowel  from  the  number  of  leukocytes  present.  Normal 
or  very  moderate  leukocytosis  in  the  first  forty-eight  hours 
of  an  obstruction  speaks  against  gangrene  of  the  bowel. 
The  higher  the  leukocyte  count  and  the  shorter  the  duration 
of  the  obstruction,  the  greater  the  danger  of  gangrene. 

(6)  Appendicitis  or  Cholecystitis. — A  rapidly  rising  count 
to  20,000  or  30,000  or  over  in  the  first  two  to  four  days  of 
an  acute  attack,  after  which  period  the  number  of  leukocytes 
remains  constantly  high,  speaks  strongly  for  abscess,  even 
though  the  pulse  and  temperature  do  not  coincide  therewith. 
A  moderate  hyperleukocytosis  or  a  normal  number  of  leu- 
kocytes may  go  with  a  mild  attack  that  does  not  result  in 
suppuration,  with  a  latent  abscess,  with  gangrene  of  the 
viscus,  or  with  diffuse  peritonitis.  The  other  clinical  evi- 
dences, pulse,  temperature,  and  the  general  and  the  local 
conditions,  must  guide  us  in  determining  the  nature  of  the 
inflammatory  process.  Sondern  maintains  that  when  the 
polynuclear  leukocytes  constitute  more  than  70  per  cent,  of 
the  total  number  of  white  blood  cells,  it  indicates  that  pus 
or  gangrene  is  present,  and  this  irrespective  whether  there 
is  a  high  total  leukocyte  count  or  not. 

If  with  an  intra-abdominal  abscess  that  is  associated  with 
a  high  leukocyte  count  there  is  a  sudden  fall  in  the  number 
of  leukocytes  and  a  coincident  deterioration  in  the  general 
condition  of  the  patient,  the  preseumption  is  strong  that 
a  rupture  of  the  abscess  into  the  peritoneal  cavity  has 
occurred. 

(c)  Typhoid  Perforation. — About  half  the  cases  have  a 
slowly  rising  leukocyte  count  (up  to  18,000  or  20,000)  during 
the  twenty-four  hours  succeeding  perforation.  In  the  other 
half  of  the  cases  the  blood  count  is  low  until  diffuse  peri- 
tonitis sets  in.  In  some  the  leukocyte  count  remains  low, 
even  with  a  diffuse  peritonitis.  Gushing  maintains  that  even 
in  the  preperforative  stage  there  is  a  moderately  increased 


42  GENERAL   CONSIDERATIONS  ON   DIAGNOSIS 

hyperleukocytosis.     In  some  of  the  author's  cases  this  has 
not  been  so. 

A  high  leukocyte  count  in  diffuse  peritonitis  is  of  good 
diagnostic  import. 

5.  In  Tuberculosis  and  Actinomycosis. — No  increased  leu- 
kocytosis accompanies  a  pure  tuberculosis  or  actinomycosis, 
no  matter  what  the  locality  or  the  activity  of  the  infecting 
bacillus  may  be.  An  increased  leukocytosis  in  these  affections 
speaks  in  favor  of  a  mixed  infection,  and  the  degee  of  leuko- 
cytosis is  usually  proportionate  to  the  severity  of  the  latter. 
High  temperatures  and  normal  number  of  leukocytes  usually 
speak  against  inflammation  and  suppuration.  High  tem- 
peratures and  hyperleukocytosis  speak  for  suppuration. 

6.  In  Neoplasms. — Benign  tumors  cause  no  change  in  the 
number  of  leukocytes.  In  malignant  growths  (carcinoma 
and  sarcoma)  the  leukocyte  count  is  inconstant. 

7.  In  Injuries. — Subcutaneous  injuries,  fractures,  etc.,  are 
associated  with  very  moderate  leukocytosis  for  about  three 
days.  Aseptic  wounds  cause  a  moderate  leukocytosis  for 
two  to  three  days.  If  this  does  not  subside  after  three  days, 
suspicion  of  wound  infection  must  be  entertained.  (Occa- 
sionally the  leukocytosis  lasts  longer  than  three  days;  if  the 
temperature  and  other  signs  point  againt  suppuration,  we 
may  delay  before  opening  the  wound.)  Suppurating  wounds 
are  attended  with  increased  leukocytosis.  (See  abscess  in 
cellular  tissues,  p.  39.) 

It  is  to  be  noted  that  our  present  knowledge  of  the  degrees 
and  constancy  of  leukocytosis  is  by  no  means  so  well  formu- 
lated as  to  warrant  our  neglect  of  other  clinical  evidences 
in  forming  an  opinion  as  to  the  presence  or  abscence  of 
suppuration,  perforation  of  a  viscus  into  the  peritoneal 
cavity,  etc.  The  needle  in  doubtful  cases  of  pleural  effusion 
or  exudates  in  the  soft  parts  is  much  more  reliable  than  the 
blood  count  for  making  a  diagnosis  of  pus.  He  will  be  a 
sorry  surgeon  who  relies  upon  the  blood  count  to  decide 
whether  or  when  to  operate  in  intestinal  obstruction.  The 
leukocyte  count  must  only  be  looked  upon  as  an  aid  in 
diagnosis,  and  not  as  a  deciding  factor.  It  is  to  be  remem- 
bered that  only  positive  findings  (hyperleukocytosis)  have  a 
value;  normal  counts  have  little  diagnostic  significance. 


CHAPTER    III. 

SURGICAL  INFECTIONS. 

In  connection  with  surgical  infections  it  is  necessary 
to  note: 

1.  That  they  are  all  due  to  pathogenic  bacteria. 

2.  That  at  the  point  of  entry  of  the  organisms  there  is 
usually  a  local  lesion;  and 

3.  That  the  constitutional  disturbances  attendinfj  the 
infection  are  due  to  the  absorption  into  the  blood  of  the 
products  of  bacterial  life  and  development — i.  e.,  the  toxins. 

The  knowledge  given  to  us  by  Pasteur  and  Koch,  that 
wound  infections  are  invariably  due  to  pathogenic  bacteria, 
should  lead  us  in  each  case  to  ascertain  the  identity  of  the 
infecting  organism,  for  the  prognosis  and,  in  some  instances, 
the  therapeutic  measures  that  are  to  be  employed  will  depend 
upon  the  character  of  the  invading  bacteria. 

The  local  lesion  bears  no  relation  to  the  severity  of  the 
constitutional  symptoms;  thus  with  the  slightest  and  mildest 
kind  of  a  local  disturbance,  and  sometimes  without  any 
discernible  local  lesion  whatever  (cryptogenic  infection), 
there  may  be  the  gravest  forms  of  constitutional  intoxication, 
and  vice  versa,  with  very  severe  local  manifestations  there 
may  be  comparatively  little  constitutional  poisoning.  The 
local  lesion  may  be  in  the  nature  of  suppuration,  as  is  the 
case  when  the  pyogenic  bacteria  are  the  invading  organisms, 
or  it  may  be  a  specific  lesion,  as  happens  when  specific 
organisms  —  &-g-,  the  streptococcus  of  erysipelas,  or  the 
anthrax  bacillus,  or  the  tubercle  bacillus,  or  actinomyces, 
etc. — are  the  infecting  agents. 

The  constitutional  symptoms  of  bacterial  infection  are 
due  to  the  absorption  of  the  toxic  products  elaborated  by 
the  invading  bacteria;  hence  the  technical  name  given  to  the 
condition  of  toxaemia.  This  is  true  whether  the  bacteria 
remain    confined   to    the    tissues    they    first  infected    (local 


44  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

infection),  or  whether  they  invade  and  infect  the  blood 
(septica?inia),  or  whether  they  are  carried  by  the  blood  and 
lodged  as  emboli  in  other  organs,  in  each  of  which  they 
inaugurate  lesions  similar  to  the  primary  one  (pyaemia). 

In  this  chapter  our  aim  will  be  to  describe  and  differ- 
entiate the  local  lesions  and  constitutional  disturbances 
resulting  from  an  invasion  of  the  tissues  with  pathogenic 
bacteria  exclusive  of  those  due  to  the  tubercle  bacillus,  the 
leprosy  bacillus,  the  as  yet  undiscovered  organism  of  syphilis, 
and  the  actinomyces.  These  will  be  found  minutely  detailed 
in  the  chapters  devoted  to  diseases  of  the  special  organs 


THE  CONSTITUTIONAL  SYMPTOMS  OF  TOXIN 
ABSORPTION. 

The  toxins  of  the  pathogenic  bacteria,  excepting  those 
produced  by  the  tetanus  bacillus  and  by  the  as  yet  undis- 
covered organism  of  hydrophobia,  when  they  are  absorbed 
into  the  system,  produce  almost  similar  constitutional  dis- 
tiu'bances.  The  symptoms  are  often  ushered  in  by  a  chill; 
the  temperature  rises  to  102°  to  104°,  and  usually  remains 
high  with  slight  remissions;  the  pulse  is  rapid,  the  skin  and 
conjunctivae  may  be  icteric,  there  is  nausea,  sometimes  vomit- 
ing and  diarrhoea,  headache  and  mild  delirium.  The  urine 
is  albuminous  and  often  contains  casts. 

The  intensity  of  the  symptoms  depends  entirely  upon  the 
virulence  of  the  infecting  bacteria,  and  upon  the  amount  of 
the  toxins  that  are  absorbed  into  the  general  circulation. 
In  some  instances  the  toxins  are  so  weak  and  so  small  in 
amount  that  few  if  any  constitutional  symptoms  are  present. 
In  the  cases  of  intensely  virulent  infections,  in  which  a  par- 
alysis of  the  medullary  centres  is  occasioned  by  the  toxins, 
the  temperature  is  subnormal,  the  pulse  is  very  rapid,  feeble 
and  thready,  the  skin  is  cold  and  cyanosed  and  bathed  in  a 
cold  perspiration,  there  is  frequent  vomiting  of  a  brownish 
material  which  contains  red  blood  cells,  and  the  urine  con- 
tains considerable  albumin  and  casts. 

In  some  cases  the  pulse  rate  is  slow,  even  though  the 
temperature  is  high,  probably  owing  to  an  irritation  of  the 


SURGICAL   INFECTIONS  45 

cardioinhibitory  apparatus.  When  pus  forms  the  temper- 
ature becomes  more  markedly  remittent  in  character.  The 
remissions  usually  occur  in  the  morning  and  are  apt  to  be 
attended  with  profuse  perspiration. 

In  pyoernia  the  temperature  curve  is  characterized  by  the 
occurrence  of  frequent  sharp  rises  and  falls.  Each  rise  is 
usually  preceded  by  a  rigor  and  the  fall  is  attended  with 
profuse  perspiration.  Each  chill  and  rise  of  temperature 
indicates  a  further  extension  of  the  infection  or  the  lodgement 
of  a  new  infected  embolus  in  one  of  the  other  organs. 

The  toxins  of  the  tetanus  bacillus  have  a  selective  action 
upon  the  motor  nerves  and  motor  cells  of  the  brain  and 
spinal  cord;  these  they  at  first  irritate  and  finally  paralyze. 
In  the  most  virulent  cases  the  symptoms  develop  in  a  few 
hours  or  days,  after  the  infection  has  occurred-;  while  in  the 
milder  cases  the  first  manifestations  appear  after  two  or 
three  weeks.  The  earliest  symptoms  are  painful  tonic 
spasms  of  the  muscles  concerned  in  opening  the  mouth 
(causing  lock-jaw),  of  the  muscles  of  the  back  of  the  neck, 
of  the  face  (causing  the  peculiar  grin-like  appearance,  the 
risus  sardonicus),  and  of  the  pharyngeal  muscles  (causing 
dysphagia).  These  spasms  soon  extend  to  the  muscles  of 
the  trunk  and  extremities.  They  become  more  and  more 
frequent,  and  the  remissions  between  them  more  partial. 
The  respiratory  muscles  are  usually  involved  late  in  the 
disease.  The  spasms  can  be  elicited  by  the  slightest  stimulus ; 
they  contort  the  body  in  various  directions;  thus,  in  an 
arched  backward  position  (opisthotonos),  in  a  doubled 
forward  position  (emprosthotonos),  etc.  A  considerable 
degree  of  fever  is  sometimes  present,  though  in  some  cases 
there  is  no  pyrexia  until  near  death,  when  the  continuous 
muscular  contractions  may  cause  it  to  rise  to  108°  to  109°. 

The  tetanic  symptoms  may  in  the  milder  cases  run  a  more" 
.chronic  course  and  the  spasms  may  be  limited  to  the  part  of 
the  body  which  has  been  the  site  of  the  infection.  Under 
this  heading  may  be  grouped  the  head  tetanus  which  follows 
injuries  within  the  area  of  distribution  of  the  cranial  nerves. 
It  is  characterized  by  an  association  of  trismus  with  facial 
paralysis,  although  there  may  be  both  tonic  and  clonic 
spasms  of  other  muscles. 


46  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

The  toxcemia  resulting  from  hydrophobia  may  first  show 
itself  months  or  even  years  after  the  infection  has  occurred; 
the  usual  period,  however,  does  not  exceed  six  weeks.  The 
infected  wound  usually  heals,  though  the  scar  may  be  tender 
and  the  seat  of  neuralgic  pain.  The  earliest  manifestations 
of  the  malady  are  restlessness,  sleeplessness,  loss  of  appetite, 
some  slight  fever,  clonic  spasms  of  the  muscles  of  the  tongue, 
of  the  neck,  of  deglutition,  and  of  respiration.  The  spasms 
become  more  and  more  generalized;  swallowing  is  impossible; 
the  mouth  is  filled  with  ropy  mucus;  respiration  is  catchy, 
and  the  noise  produced  by  spasm  of  the  diaphragm  is  some- 
times thought  to  resemble  the  bark  of  a  dog.  The  disease 
usually  kills  in  a  week. 

With  most  of  the  acute  infections  there  is  a  hyperleuko- 
cytosis.  Sondern  believes  that  when  the  polynuclear  white 
blood  cells  number  more  than  70  per  cent,  of  the  total 
number  of  the  leukocytes  pus  is  present. 

It  is  always  easy  to  correctly  interpret  the  constitutional 
symptoms  above  detailed  when  there  is  a  local  lesion  present. 
It  is  not  so  easy,  nor  by  any  means  always  possible,  to 
determine  whether  the  local  infection  alone  accounts  for  the 
toxic  symptoms,  or  whether  there  is  also  an  infection  of  the 
blood  with  the  pathogenic  organisms — i.  e.,  a  septicaemia. 
The  severity  of  the  symptoms  is  no  guide,  for  with  severe 
purely  local  infections  there  may  be  an  intense  grade  of 
constitutional  symptoms,  and  with  milder  blood  infections 
the  symptoms  may  be  of  only  moderate  severity.  It  is  im- 
portant to  remember  that  a  blood  infection  frequently  occurs 
very  shortly  after  the  local  infection  has  taken  place  and 
also  that  the  blood  infection  may  precede  the  manifestation 
of  the  local  lesion.     (See  Osteomyehtis.) 

Very  frequently  we  shall  be  able  to  decide  the  question 
of  blood  infection  by  observing  the  course  of  the  symptoms 
after  the  local  lesion  has  been  properly  treated.  If  the 
toxaemia  is  dependent  entirely  upon  the  local  trouble,  then 
it  should  subside  within  forty-eight  to  seventy-two  hours 
after  this  has  been  relieved.  If,  however,  it  is  dependent 
upon  a  blood  infection,  its  manifestations  will  continue  un- 
abated in  spite  of  a  subsidence  of  the  local  lesion. 

In  all  such  latter  cases,  and  also  in  those  where  from  the 


SURGICAL  INFECTIONS  47 

severity  of  the  constitutional  disturbances  we  suspect  the 
existence  of  a  blood  infection,  we  should  have  a  blood  culture 
taken.  A  positive  culture  is  conclusive  evidence  of  a  septi- 
CEcmia,  but  a  negative  one  is  not  to  be  construed  as  simi- 
larly conclusive  that  a  blood  infection  is  not  present. 

The  cases  of  cryptogenic  septicaemia — i.  e.,  cases  of  blood 
infection  for  which  no  local  lesion  can  be  discovered — offer 
the  greatest  difficulty  in  diagnosis.  Only  by  continued 
observation  and  by  a  gradual  exclusion  of  all  other  maladies 
can  we  hope  to  arrive  at  a  diagnosis  in  these  cases;  this  is 
always  to  be  confirmed  by  a  blood  culture.  It  is  well  in 
these  cases  to  remember  that  scratches,  abrasions,  hang  nails, 
urethritis,  pin  pricks,  etc.,  may  be  the  portal  of  entry  for  the 
bacteria  into  the  blood  stream. 

The  constitutional  symptoms  arising  from  a  local  infection 
or  from  a  septicaemia  are  readily  distinguished  from  those  due 
to  a  pyaemia,  by  the  absence  of  the  repeated  rigors  and 
secondary  abscesses  which  characterize  the  latter  condi- 
tion. 

The  cases  of  cryptogenic  pyaemia  may  be  mistaken  for 
cases  of  malaria.  The  absence  of  plasmodia  in  the  blood, 
and  an  irregularity  in  the  occurrence  of  the  rigors,  distinguish 
the  pyaemic  condition.  It  is  not  wise,  in  doubtful  cases,  to 
at  once  administer  quinine,  for  the  antipyretic  action  of  this 
drug  disturbs  the  temperature  curve  and  so  deprives  us  of 
one  of  the  best  differential  diagnostic  signs. 

The  tetanic  spasms  induced  by  the  toxins  of  tetanus  may 
in  rare  instances  be  confused  with  those  due  to  strychnine 
poisoning.  In  the  latter  condition,  however,  the  spasms  are 
less  intense  and  between  them  there  is  complete  relaxa- 
tion, whereas  in  tetanus  there  is  no  complete  relaxation 
between  the  spasms. 

The  clonic  spasms  attending  hydrophobia  at  once  distin- 
guish this  malady  from  tetanus,  in  which  affection  the  spasms 
are  of  a  tonic  character. 


48  GENERAL  CONSIDERATIONS  ON  DIAGNOSIS 


THE  LOCAL  LESIONS  RESULTING  FROM  WOUND 
INFECTIONS. 

Here,  as  in  dealing  with  the  constitutional  manifestations 
of  wound  infections,  we  will  not  consider  the  local  evidences 
produced  by  the  tubercle  bacillus,  the  syphilitic  virus,  the 
leprosy  bacillus,  or  the  aetinomyces.  These  lesions  are 
minutely  described  in  the  succeeding  chapters. 

An  infection  of  the  tissues  with  the  pyogenic  bacteria,  of 
which  the  staphylococcus  pyogenes  aureus,  alhus  and  citreus, 
the  streptococcus  pyogenes,  the  bacillus  coli  communis,  the 
bacillus  pyocyaneus,  the  pneumococcus,  the  bacillus  typhosus 
and  the  gonococcus  are  the  most  important,  leads  to 
suppuration.  If  the  pus  is  localized,  the  condition  is  spoken 
of  as  an  abscess;  if  it  is  widely  distributed  in  the  cellular 
tissue  the  process  is  termed  a  cellulitis.  An  acute  abscess 
forms  a  hot,  painful  swelling,  hard  and  brawny  at  the  outset, 
and  later  on  becoming  soft,  elastic,  and  fluctuant.  If  it  is 
superficially  located,  the  overlying  skin  is  hot  and  reddened. 
With  acute  pus  formation  there  is  considerable  hyperleukocy- 
tosis,the  polyneuclear  cells,  according  to  Sondern,  constituting 
over  70  per  cent,  of  the  total  number  of  white  cells.  There  is 
never  any  difficulty  in  recognizing  a  superficial  acute  abscess ; 
the  deeper  ones  are  sometimes  very  hard  to  make  out,  and 
inasmuch  as  fluctuation  is  not  always  to  be  obtained,  it  is 
well  to  aspirate  in  every  case  where  we  suspect  the  presence 
of  deep-seated  pus.  Abscesses  lying  over  and  accompanying 
the  larger  arteries  share  the  pulsation  of  the  vessels  and  over 
them  can  be  heard  a  systolic  murmur;  they  may  consequently 
be  mistaken  for  aneurysms.  The  error  is  especially  apt  to 
arise  in  the  case  of  chronic  abscesses  which  are  not  attended 
by  local  heat  and  redness;  it  will  be  avoided  if  we  remember 
that  aneurysms  are  usually  compressible  and  have  an  expan- 
sile pulsation  which  abscesses  never  possess. 

When  an  abscess  has  been  opened  and  does  not  com- 
pletely heal,  a  communication  will  often  persist  between  the 
original  seat  of  the  disease  and  the  surface  of  the  body;  such 
a  communication  is  known  as  a  sinus  or  fistula.  A  sinus 
is  a  granulating  tract  which  penetrates  into  the  tissues,  and 


SURGICAL  INFECTIONS 


49 


is  open  at  one  end  and  closed  at  the  other.  A  fistula  is  an 
abnormal  communication  between  two  cavities  or  between 
a  cavity  and  the  external  surface. 

Infection  of  the  superficial  tissues  sometimes  results  in 
their  molecular  death,  which  gives  rise  to  ulceration.  The 
ulcers  which  follow  infection  with  the  pyogenic  bacteria  have 
an  ash-gray,  or  dirty  yellowish  color;  their  edges  are  sharply 


Fig.  5 


Granulating  ulcers  of  the  leg,  resulting  from  infection  witb  pyogenic  bacteria. 
Note  the  sharp  edges  and  the  thickened  margins. 


cut;  their  base  is  fixed  to  the  underlying  structures;  their 
margins  are  thickened,  inflamed,  and  oedematous;  their 
surface  is  non-granulating,  and  their  discharge  is  consider- 
able in  amount,  thin,  sanious,  often  irritating  and  offensive, 
andFrarely  purulent. 

Gangrene — i.  e.,   the  simultaneous  loss   of  vitality    of    a 
considerable  area  of  tissue — may  likewise  result  from  infec- 

4 


50  GENERAL   CONSIDERATIONS  ON  DIAGNOSIS 

tions  when  the  bacteria,  either  by  emboHsm  or  thrombosis, 
cause  an  obstruction  of  the  bloodvessels  and  so  interfere  with 
the  circulation  of  the  affected  part.  This  form  of  gangrene 
is  always  a  septic  one;  the  affected  tissues  rapidly  dis- 
integrate, become  black,  green,  and  yellow,  the  overlying 
cuticle  is  raised  from  the  true  cutis  by  blebs  which  contain 
a  fetid  serum.  In  the  cases  in  which  the  infecting  organisms 
are  of  the  gas-producing  types  (especially  the  bacteria  aerog- 
enes  capsulatus)  the  tissues  crackle  on  palpation. 

Carbuncles  and  boils  are  described  in  detail  on  page  126. 

Infection  of  the  smaller  lymphatics  of  the  skin,  or  of 
the  mucous  membranes,  with  the  streptococcus  erysipe- 
latis^  (Fehleisen)  gives  rise  to  erysipelas.  This  infection 
manifests  itself  by  a  uniform,  bright,  rosy-red  rash  with 
sharp,  slightly  elevated  borders ;  it  is  not  attended  with  much 
swelling  except  when  the  affected  part  is  rich  in  loose  areolar 
tissue — e.  g.,  scrotum  or  eyelids;  it  disappears  on  pressure 
and  tends  to  spread  from  its  initial  site  more  or  less  rapidly, 
either  with  a  continuous  margin  or  in  jumps,  leaving  a 
healthy  interval  between  the  areas  involved.  The  infected 
part  feels  stiff  and  burns,  but  it  is  not  usually  painful;  as 
the  rash  fades  away,  it  leaves  the  skin  stained  slightly  brown, 
and  covered  with  a  fine  branny  desquamation.  Sometimes 
the  epidermis  is  raised  into  vesicles  and  bullae,  and  in  some 
instances  the  infection  invades  the  deeper  lymphatics  and 
occasions  suppuration. 

The  uniformity  of  the  redness  which  goes  with  erysipelas 
distinguishes  this  affection  from  a  lymphangitis,  in  which  the 
redness  is  in  streaks  or  lines. 

The  redness  of  the  skin  attending  a  superficial  abscess  or 
suppuration  in  the  subcutaneous  cellular  tissue  very  strongly 
simulates  an  erysipelatous  redness,  but  it  is  not  so  sharply 
defined,  nor  are  its  edges  elevated. 

The  dermatitis  due  to  iodoform  and  its  allied  preparations  may 
strongly  simulate  erysipelas.  The  lesion,  however,  is  strictly 
limited  to  the  region  which  is  covered  by  the  toxic  agent,  the 
constitutional  symptoms  are  not  so  severe,  and  the  redness 
at  once  subsides  when  the  irritating  material  is  removed. 

1  Some  bacteriologists  consider  that  the  streptococcus  of  erysipelas  is  identical  with 
the  ordinary  streptococcus  pyogenes. 


SURGICAL  INFECTIONS  51 

Erythema  nodosum  is  attended  with  a  slighter  grade  of 
constitutional  disturbances  than  is  erysipelas;  the  lesion 
occurs  most  often  on  the  legs,  in  young  women  of  a  rheu- 
matic tendency,  and  the  redness  is  more  sharply  defined. 

The  local  lesion  resulting  from  anthrax  infection  (malignant 
pustule)  is  fully  described  on  page  126.  A  general  infection 
with  anthrax  bacilli  without  external  lesion  is  sometimes 
found  in  those  who  handle  hides,  for  which  reason  the  malady 
is  termed  wool-sorters'  disease.  The  organisms  gain  entrance 
either  through  the  intestinal  or  respiratory  tracts.  If  through 
the  latter,  a  septic  pleuropneumonia  develops;  if  through  the 
former,  a  septic  gastroenteritis. 

The  local  lesion  of  the  mucous  membranes  of  the  genito- 
urinary system,  eyes,  synovial  membrane,  etc.,  following  a 
gonococcus  infection  consists  of  a  catarrhal  or  suppurative 
or  ulcerative  inflammation  of  these  parts.  They  are  minutely 
dealt  with  in  the  chapter  devoted  to  diseases  of  the  genito- 
urinary system,  joints,  etc.,  and  are  to  be  differentiated  from 
the  infectious  processes  due  to  other  types  of  bacteria  only  by 
bacteriological  examination. 


PART  II. 
INJURIES  AND  DISEASES  OF  HEAD  AND  NECK. 


CHAPTER   IV. 

TUMORS  AND  INFLAMMATORY  DISEASES  OF  THE  HEAD. 

CONGENITAL  TUMORS. 

Babies  are  sometimes  born  with  swellings  on  their  heads. 
Of  these  the  most  frequent  though  the  least  important  is  the 
ca'put  succedaneum,  an  oedematous  condition  of  the  scalp, 
always  lying  on  one  side  of  the  median  line  and  disap- 
pearing spontaneously  a  few  days  after  birth.  More  sig- 
nificant is  the  cephalhcematoma — i.  e.,  a  collection  of  blood 
beneath  the  periosteum,  which,  at  its  first  appearance,  is  a 
soft,  elastic,  semifluctuating  or  doughy,  irreducible  tumor 
limited  to  one  bone  and  never  overstepping  the  boundaries 
of  the  sutures,  but  later  on  becoming  harder  and  firmer  and 
very  often  surrounded  by  a  raised  wall  of  bony  tissue  that 
simulates  the  margins  surrounding  a  depressed  fracture. 
Most  significant  is  the  congenital  jjrotrusion  of  the  cranial 
contents,  brain  and  membranes  or  membranes  alone  or  vas- 
cular sinuses,  through  an  opening  in  the  skull  situated  along 
the  meeting  'place  of  one  or  more  of  the  bones. 

These  abnormal  openings  in  the  skull  are  situated  in  the 
order  of  their  frequency  of  occurrence: 

1.  On  the  back  of  the  head,  above  or  below  the  occipital 
protuberance. 


54     INJURIES  AND  DISEASES  OF  HEAD   AND   NECK 

2.  In  the  region  of  the  root  of  the  nose,  either  nasofrontal 
between  the  nasal  and  frontal  bones,  or  naso-orbital. 

3.  In  the  region  of  the  sagittal  suture. 

4.  In  the  region  of  the  mastoid  or  the  condylosquamosal 
suture. 

5.  At  the  base  of  the  skull  between  the  ethmoid   and 
sphenoid  bones,  or  between  the  ethmoid  and  nasal  bones. 

The  last  two  sites  are  infrequent. 


Fig.  fi 


Cephalhsematoma  over  the  left  parietal  bone.  Note  its  sharp  limitations  by  the 
frontoparietal  suture  in  front,  by  the  sagittal  suture  internally,  and  by  temporoparietal 
suture  below. 


These  hernial  tumors  are  rounded  or  pear-shaped,  with 
broad  base  and  narrow  pedicle,  and  pulsate.  The  overlying 
scalp  is  smooth  or  wrinkled  or  stretched  or  ulcerated,  or  it 
is  the  seat  of  telangiectasis. 


TUMORS  AND   INFLAMMATORY   DISEASES 


55 


If  the  tumor  is  cystic,  fluctuating,  and  translucent,  it  is  a 
meningocele} 

If  it  is  soft,  elastic,  and  more  or  less  opaque,  depending 
upon  the  proportion  of  brain  substance  it  contains,  it  is  an 
encephalocele,^  and  if  it  is  bluish  in  color,  easily  replaced 
into  the  cranial  cavity,  and  has  marked  respiratory  pulsa- 
tion, it  is  a  cephalhcBmatocele — i.  e.,  a  prolapsed  vascular 
sinus. 


Fig. 


Nasofrontal  cephalocele.    (Von  Bergmaun.) 

An  encephalocele  or  false  meningocele  will  become  tense 
on  straining  or  crying  only  when  its  cavity  communicates 
with  the  ventricle  proper;  in  some  of  such  cases  pressure 
upon  the  tumor  produces  symptoms  of  cerebral  compression. 

Before  a  diagnosis  of  a  cranial  hernia  is  made  the  margins 


1  True  meningoceles,  which  are  of  rare  occurrence  and  consist  of  a  sac-like  protru- 
sion of  the  arachnoid  filled  with  cerebrospinal  fluid  derived  from  the  subarachnoid 
space,  are  not  to  be  confounded  histologically  with  the  encephalomeningoceles, 
which  by  reason  of  a  thinning  out  of  the  brain  cortex  overlying  the  cavity  of  the 
protruded  part  while  the  channel  of  communication  between  this  cavity  and  the 
ventricle  proper  becomes  very  narrow  or  entirely  closed,  form  a  cystic  tumor  covered, 
apparently  only  by  arachnoid  (false  meningocele). 

-  If  only  the  brain  cortex  with  its  overlying  membranes  protrudes  from  the  skull, 
the  hernia  is  spoken  of  as  a  kenencephalocele;  if  the  arachnoid  covering  the  pro- 
truding brain  and  ventricle  becomes  the  seat  of  a  cystic  degeneration  with  the  forma- 
tion of  one  or  more  cysts,  the  tumor  is  spoken  of  as  an  encephalocystomeningocele. 


56     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

of  the  opening  in  the  skull  through  which  it  emerges 
should  be  palpated  or  viewed  with  the  Roentgen  rays. 
The  presence  of  an  opening  in  the  skull  at  once  differen- 
tiates such  tumors  from  the  caput  succedaneum  and  the 
cephalhsematoma.  These  latter  are,  further,  irreducible, 
and  always  to  one  side  of  the  median  line,  and  possess 
none  of  the  characteristics  of  cranial  hernise. 

At  puberty  these  cranial  hernise  may  be  confounded  with 
pulsating  dermoid  cysts,  but  the  latter  do  not  occupy  the 
same  regions  in  the  skull  as  do  encephaloceles,  they  cannot 


Fig.  8 


Inferior  occipital  cephalocele.    (Von  Bergmann.) 


be  reduced  into  the  cranium,  and  on  aseptic  puncture  yield 
an  oily,  cheesy  material;  whereas,  encephaloceles  and  menin- 
goceles yield  a  clear,  yellowish  fluid  that  contains  grape- 
sugar. 

Varicose  veins  of  the  scalp  are  to  be  differentiated  from 
cephalhsematoceles  by  their  not  reappearing  after  reduction, 
while  the  scalp  surrounding  the  varix  is  firmly  compressed. 
Cephalhsematoceles  deriving  their  blood  from  within  the 
cranial  cavity  reappear  in  spite  of  such  circular  compres- 
sion of  the  scalp. 


TUMORS  AND  INFLAMMATORY   DISEASES  57 

Cephaloceles  protruding  through  the  nose  have  been  mis- 
taken for  polypi.  Fenger  claims  that  a  wide  separation  of 
the  eyes  and  a  very  high  attachment  of    the  pedicle  of  the 

Fig.  9 


Cephalocele  protruding  through  the  occipital  bone  below  the  external  occipital 
protuberance,  and  through  the  atlas. 

supposed  polypus  are  suggestive  of  encephalocele.  Aspira- 
.tion  alone  can  decide  the  diagnosis  in  these  cases.  The 
aspirated  fluid  should  contain  grape-sugar  if  the  tumor  is  a 
cephalocele. 


58     INJURIES  AND   DISEASES  OF  HEAD  AND  NECK 

NEOPLASMS  OF  SCALP. 

Aneurysmal  tumors,  lipomata,  and  papillomata  offer 
little  difficulty  in  their  diagnosis. 

Sebaceous  Cysts. — -These  are  situated  in  or  underneath 
the  skin,  and  form  tense,  soft  tumors  of  hazel-nut  to  walnut 
size.  They  are  usually  multiple.  They  are  to  be  differenti- 
ated from 

Dermoid  Cysts. — These  are  more  deeply  situated,  usually 
under  the  deep  fascia  and  in  a  shallow  trough  of  bone; 
they  are  adherent  to  the  periosteum  and  bone  and  are  con- 
sequently less  movable  than  sebaceous  cysts.  Their  favor- 
ite sites  are  on  the  outer  and  upper  wall  of  the  orbital 
region,  the  glabella,  the  temporoparietal  region,  the  mastoid 
region,  and  the  large  fontanelle.  They  are  congenital,  grow 
very  slowly,  and,  as  a  rule,  are  not  noticed  until  puberty. 
The  trough  of  bone  in  which  the  cyst  lies  may  be  very 
deep;  occasionally  its  floor  is  entirely  absorbed  and  the  cyst 
thus  comes  to  lie  directly  upon  the  dura,  whose  pulsation  it 
shares  (pulsating  dermoid  cyst).  Such  pulsating  cysts  are 
to  be  distinguished  from  encephaloceles  by  their  location 
(situated  in  the  neighborhood  of  the  eye,  about  the  margin 
of  the  orbit),  by  their  irreducibility  within  the  cranium, 
and  by  aseptic  aspiration.  (Dermoids  contain  an  oily  fluid, 
encephaloceles  a  clear,  yellowish  fluid  which  has  a  small 
amount  of  grape-sugar.) 

Carcinoma  of  the  Scalp. — This  is  most  frequently  found 
in  the  frontal  or  parietal  regions.  It  is  usually  of  the  rodent 
ulcer  type,  but  sometimes  occurs  as  deeper  infiltrations 
which  originate  in  the  sebaceous  glands  and  hair  follicles. 

The  tumor  has  the  usual  characteristics  of  carcinoma;  it 
is  hard,  fixed  upon  the  skull,  with  indefinite  outlines,  and  is 
somewhat  painful  and  tender.  When  it  breaks  down  the 
ulcer  that  is  formed  has  hard,  everted  edges,  and  the  base  is 
covered  with  unhealthy,  easily  bleeding  granulations  and 
crusts. 

One  of  the  superficial  forms  of  carcinoma  of  the  scalp 
resembles  lupus.  It  commences  with  multiple,  flattened 
papules,  the  epithelial  covering  of  which  is  excoriated;  as 


TUMORS  AND   INFLAMMATORY  DISEASES  59 

new  papules  form  in  an  advancing  convex  border  the  old 
ones  cicatrize.  The  diagnosis  from  lupus  is  made  by  the 
absence  of  all  reaction  after  tuberculin  injection. 

Sarcoma  of  Scalp. — Sarcoma  of  the  scalp  is  rare;  it  is 
usually  secondary  to  sarcoma  of  the  periosteum  or  diploe 
or  dura. 

DISEASES  OF  THE  SKULL. 

Tuberculosis  of  the  Bones  of  the  Skull. — This  involves 
most  frequently  the  frontal  and  parietal  bones,  and,  as  a 
rule,  the  affection  is  secondary  to  tuberculous  lesions  in 
other  organs.  The  primary  form  of  the  disease  first  mani- 
fests itself  by  a  circumscribed,  oedematous,  tender  swelling 
of  the  overlying  soft  parts,  which  goes  on  to  cheesy  degen- 

FiG.  10 


Pneumatocele  resulting  from  necrosis  of  frontal  bone.  Note  the  location  over  the 
frontal  sinuses.  Similar  subperiosteal,  air-containing,  elastic  and  painless  tumors  are 
frequently  found  over  the  mastoid  and  over  the  superior  maxilla. 

eration,  abscess  formation,  and  ulceration.  The  tubercu- 
lous disease  eats  its  way  inward  toward  the  membranes  and 
sinuses  of  the  brain,  as  well  as  outward  toward  the  scalp. 
Perforation  outward  occurs  late  on  account  of  the  firmness 
of  the  facial  layers.  Perforation  inward  is  followed  by 
meningitis  or  general  tuberculosis. 


60     INJURIES  AND   DISEASES  OF  HEAD  AND  NECK 


Fig.  11 


Tuberculosis  of  skull,  the  pericranium  having  been  reflected  back.      Note  the  worm- 
eaten  character  of  the  sequestrum.     (Duplay  and  Reclus.) 


Fig.  12 


Tuberculosis  of  skull  seen  from  the  internal  aspect  of  the  bone.      Note  the  large 
tuberculous  fungosities.    (Duplay  and  Reclus.) 


TUMORS  AND  INFLAMMATORY  DISEASES 


61 


The  diagnosis  is  made    from  the  chronic  course  of  the 
disease,  the  presence  of  the  tubercle  bacilh  in   the   cheesy 

Fig.  13 


Syphilitic  necrosis  of  the  skull.    (Von  Bergmann.) 
Fig. 14 


Hereditary  syphilis :  gumraata  of  the  cranial  bones.    Child,  aged  eighteen 
months.    (Koplik.) 


62     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

material,  and  from  the  presence  of  tuberculous  lesions  in  other 
organs. 

Syphilis  of  the  Skull  Bones. — This  is  likewise  found 
most  frequently  in  the  frontal  and  parietal  bones.  It  may 
be  a  primary  process  in  the  pericranium  or  diploe  or  it  may 
be  secondary  to  syphilis  of  the  scalp. 

Single  and  circumscribed  or  more  diffuse  and  multiple, 
soft,  elastic,  flat  tumors,  having  no  inflammatory  evidences, 
and  with  no  tenderness,  are  indicative  of  gummata.     They 

Fig.  15 


]>arge  ulcerations  resulting  from  extensive  periosteal  gummata.    These  are  frequent 
sites  for  this  malady.    Note  the  undermined  edges  of  the  ulcers,  etc. 

rarely  undergo  ulceration.  They  cause  bone  caries  and 
necrosis,  with  possible  exposure  of  the  meninges  and  sinuses, 
and  also  give  rise  to  considerable  and  irregular  thickening 
of  the  periosteum  and  bone. 

Gummata  are  to  be  differentiated  from  tuberculous  swell- 
ings of  the  bones  by  their  lack  of  tenderness  and  by  the 
absence  of  all  evidences  of  inflammation.  There  is  frequently, 
furthermore,  a  history  of  syphilis,  and  there  are  likely  to  be 
other  syphilitic  lesions.  The  administration  of  iodide  of 
potassium  is  followed  by  a  disappearance  of  the  tumor. 


TUMORS  AND  INFLAMMATORY  DISEASES  63 

Cephalhsematoma.— The  cephalheematoma  of  the  new- 
born, and  the  subperiosteal  or  subfascial  haematoma  of  later 
life,  form  soft,  elastic,  semifluctuating  or  doughy  tumors 
which  are  limited  to  one  bone,  and  never  overstep  the  boun- 
daries of  the  sutures.  The  swelling  is  surrounded  by  a  ridge. 
In  the  newborn  a  cephalhsematoma  that  is  surrounded  by 
a  considerable  ridge  might  give  one  the  impression  of  an 
encephalocele.  But  these  cephalhsematomata  are  located 
over  one  or  the  other  of  the  parietal  bones,  where  an 
encephalocele  never  occurs. 

Osteomata. — Osteomata  of  the  skull  are  hard,  sessile, 
smooth,  painless  tumors  of  very  slow  growth.  They  may 
occasionally  be  confounded  with  myelogenous  sarcoma,  from 
which  they  are  to  be  differentiated  by  their  slower  growth 
and  their  painlessness. 

Sarcomata. — Sarcomata  originate  in  the  periosteum  or 
diploe;  they  grow  very  rapidly,  involve  the  scalp  early,  and 
undergo  ulceration,  forming  large  fungous,  bleeding  masses. 
They  may  be  very  vascular  and  have  distinct  cardiac  pulsa- 
tion. A  sarcoma  of  the  diploe  is  in  its  early  stages  covered 
by  a  thin  lamella  of  bone  (the  outer  table),  which  crackles 
on  palpation  (the  characteristic  egg-shell  crackle  of  mye- 
logenous sarcoma).  This  feature  enables  us  to  differentiate 
a  diploic  sarcoma  from  a  sarcoma  of  the  dura,  which  has 
involved  and  then  absorbed  the  overlying  bone,  and  which 
does  not  manifest  this  crackling  sensation.  In  the  later 
stages  of  diploic  sarcoma  there  is  no  characteristic  egg-shell 
crackle,  as  the  outer  table  has  been  gradually  absorbed  by 
the  neoplasm.  Fragments  of  it,  however,  especially  at  the 
margins  of  the  tumor,  remain,  and  these  fragments  are  valu- 
able diagnostic  evidence  of  diploic  as  against  dural  sar- 
coma. Excessive  new  formation  of  bone  at  the  base  of 
the  tumor  is  further  evidence  of  a  bony  as  against  a  dural 
growth.  Dural  sarcoma  in  its  early  stages  is  further  likely 
to  be  reducible  within  the  cranial  cavity,  and  is  more  apt 
to  give  rise  to  subjective  symptoms  of  cerebral  compres- 
sion, such  as  headache,  convulsions,  etc. 

Akeidopeirastik,  i.  e.,  puncture  of  the  tumor  with  a 
needle,  is  another  valuable  method  for  differentiating  dural 
from  diploic  sarcoma.     If  the  exploring  needle  when  it  is 


64     INJURIES  AND   DISEASES  OF  HEAD  AND  NECK 

introduced  into  the  tumor  impinges  upon  bones  it  indicates 
a  diploic  sarcoma  that  has  not  penetrated  the  vitreous 
lamina  of  the  bone. 

Aneurysm  of  Bones. — Aneurysm  of  the  bones  resembles 
very  much  a  diploic  sarcoma.     It  forms  a  soft,  non-tender 


Fig.  16 


Fig.  17 


Fig.  16. — Diploic  sarcoma  of  parietal  bone.    (Albert.) 
Fig.  17.— Aneurysms  of  the  skull  bones.    (W.  Busch.) 

tumor  with  expansile  pulsation,  and  over  it  can  be  heard  a 
systolic  murmur  and  a  bruit.  *  It  is  easily  reducible  (i.  e., 
made  to  disappear)  and  stays  reduced  when  the  carotid 
artery  is  compressed.  The  opening  in  the  bone  through 
which  the  tumor  appears  can  be  palpated  when  the  latter 
is  reduced. 


CHAPTER   V. 

INJURIES  OF  THE  HEAD. 

Injuries  of  the  liead  derive  their  chief  clinical  significance 
from  the  character  and  extent  of  the  lesions  the  trauma  pro- 
duces in  the  brain  and  its  enveloping  membranes.  In  deal- 
ing with  cranial  injuries  the  diagnostician's  main  concern 
is  to  determine  whether  a  cerebral  lesion  is  present,  and,  if 
so,  what  its  nature  and  localization  are.  Wounds  of  the 
soft  parts  are  important  only  in  so  much  as  they  open  up 
an  avenue  for  primary  or  subsequent  infection  of  the  brain 
and  meninges;  while  the  wounds  and  fractures  of  the  bony 
capsule  are  of  interest  partly  because  the  fragments  of  the 
bone  may  be  depressed,  and  so  cause  compression  of  the 
brain,  partly  because  the  application  of  a  force  sufficient  to 
fracture  a  bone  will  probably  also  result  in  cerebral  concus- 
sion, contusion,  or  laceration,  or  in  rupture  of  bloodvessels, 
and  also  because  a  secondary  osteomyelitis  may  follow  the 
injury  and  at  a  future  time  give  rise  to  cerebral  or  menin- 
geal lesions. 

,  The  presence  of  cerebral  complications  is  always  to  be 
determined  from  the  symptoms.  If  there  are  or  have  been 
no  cerebral  symptoms,  such  as  headache,  vomiting,  stupor, 
unconsciousness,  paralyses,  convulsions,  slow  pulse,  and 
slow  respiration,  there  is,  as  a  rule,  no  complicating  cerebral 
condition.  It  is  to  be  remembered,  however,  that  the  injury 
may  have  occasioned  very  slight  primary  cerebral  symptoms 
and  yet  have  produced  a  rupture  of  the  middle  meningeal 
artery  or  of  one  of  the  vascular  sinuses,  in  virtue  of  which 
there  will  be  manifested  within  a  few  hours  the  evidences 
of  cerebral  compression.  It  is  always  wise,  therefore,  to  be 
guarded  in  estimating  the  severity  of  any  cranial  injury 
immediately  after  its  infliction,  and  not  to  express  an  opinion 
as  to  the  existence  of  cerebral  complications  until  twenty-four 
hours  have  elapsed. 

The  nature  of  the  cerebral  injury  is  determined  from  the 
character  of  the  symptoms. 

5 


66     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 


CONCUSSION. 

Concussion  is  always  transient  in  its  manifestations,  the 
chief  of  which  are  unconsciousness  and  slow  pulse. 

Mild  Form. — In  the  mildest  cases  the  individual  is  stunned 
or  dazed,  possibly  unconscious,  but  presents  no  marked 
changes  in  pulse,  respiration,  or  temperature. 

Moderately  Severe  Forms. — In  the  moderately  severe 
forms  the  patient  becomes  dizzy,  sees  spots  before  his  eyes, 
has  tinnitus  aurium,  and  falls  to  the  ground  unconscious, 
the  muscular  system  being  weak  and  relaxed.  The  face  is 
pale,  the  expression  blank,  the  eyelids  closed,  the  pulse  small, 
feeble,  and  slow,  and  the  respirations  very  superficial.  The 
temperature  is  subnormal.  Recovery  is  the  rule.  After  a 
little  while  the  patient  takes  a  few  deep  breaths,  opens  his 
eyes,  stares  around,  and  gradually  returns  to  consciousness, 
the  pulse  becoming  stronger  and  more  rapid  and  the  respira- 
tions deeper.  Memory  of  the  accident  is  usually  lost;  at 
times  there  is  amnesia  of  the  facts  preceding  the  injury. 

Severest  Forms. — In  the  severest  forms  the  coma  is 
deeper,  the  pulse  slower  and  irregular,  the  respirations  shal- 
low and  irregular,  and  the  cornea  insensitive.  The  pupils 
may  be  contracted  or  moderately  dilated  and  react  to  strong 
light.  Urine  and  stools  may  be  retained  or  they  may  be 
passed  involuntarily.  Repeated  vomiting  occurs,  especially 
directly  after  the  injury.  This  condition  lasts  for  hours 
or  even  days,  but  reaction  usually  follows,  the  pulse  becom- 
ing stronger  and  more  rapid,  the  respirations  deeper,  the 
skin  warm,  and  consciousness  returning.  In  the  fatal  cases 
the  coma  becomes  deeper,  the  pulse  slower,  until  just  before 
death,  when  it  is  rapid  and  feeble,  and  there  are  convulsions 
and  paralyses. 

Reaction  from  concussion  is,  as  a  rule,  followed  by  a 
period  of  exaltation,  during  which  the  patients  suffer  with 
headache  and  have  a  hard,  rapid  pulse. 

Simple  concussion  is  only  to  be  diagnosticated  when  the 
reaction  is  prompt.  The  longer  the  coma  lasts,  the  more 
likely  are  there  to  be   other  circumscribed  or  diffuse  cere- 


INJURIES  OF   THE  HEAD  67 

bral  lesions.  In  the  fatal  cases  there  are  usually  other 
cerebral  lesions.  It  is  further  to  be  remembered  that  the 
reaction  may  pass  into  or  be  followed  by  the  evidences  of 
acute  cerebral  compression.  Transient  loss  of  conscious- 
ness and  slow  pulse  are  the  striking  evidences  of  concussion. 
Continued  unconsciousness  points  to  some  other  cerebral 
lesion. 


COMPRESSION  OF  THE  BRAIN. 

Compression  of  the  brain  is  not  transient.  Unless  it  is 
relieved  by  operation  it  will  last  until  the  compressing  agent 
is  removed  by  absorption  or  until  the  patient  dies.  It 
follows  intracranial  blood  extravasation,  depressed  fractures 
of  the  skull,  penetrating  foreign  bodies,  and  intracranial  in- 
flammatory exudates,  and  is  usually  complicated  by  cere- 
bral concussion  or  other  cerebral  lesion. 

Its  chief  manifestations  are  slow  pulse  and  respiration, 
deep  coma,  and  choked  disk,  besides  the  local  symptoms 
from  the  area  which  is  directly  compressed.     (See  p.  70.) 

Almost  characteristic  of  compression  resulting  from  rup- 
ture of  the  middle  meningeal  artery  is  a  lucid  period  between 
the  reaction  from  the  primary  concussion  and  the  first  evi- 
dences of  compression. 

With  rupture  of  the  vascular  sinuses  or  of  the  vessels  of  the 
pia  mater  this  lucid  period  is  of  considerably  longer  dura- 
tion. If  with  such  injuries  there  happens  to  be  an  external 
wound,  so  that  the  blood  can  flow  out  of  the  skull,  its  stream 
is  a  continuous  one  and  is  to  be  readily  checked  by  com- 
pression or  packing  of  the  outer  wound.  If  the  internal 
hemorrhage  is  small  in  amount,  and  localized  to  one  area, 
there  will  be  evidence  of  local  compression  from  this  area 
(see  p.  70),  but  no  general  signs  of  compression. 

If  the  internal  hemorrhage  accumulates  rapidly  and  is 
extensive,  the  lucid  interval  may  be  altogether  wanting. 
Small  tears  of  the  sinuses  may  not  occasion  any  symptoms 
of  compression,  the  bleeding  being  spontaneously  checked 
by  the  compression  of  the  walls  of  the  sinus  against  the 
bonv  groove  in  which  it  lies. 


k 


68     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Rupture  of  the  cerebral  carotid  is  rare  and,  as  a  rule,  re- 
sults in  immediate  death.  In  some  instances  a  communica- 
tion between  the  artery  and  one  of  the  neighboring  venous 
sinuses  results,  with  the  formation  of  an  arteriovenous 
aneurysm,  the  prominent  symptom  of  which  is  a  pulsating 
exophthalmos. 

CEREBRAL  LACERATION. 

With  cerebral  laceration  the  primary  concussion  is  more 
severe  and  is  followed  by  a  disturbed  function  of  the  affected 
part.  If  this  happens  to  be  one  of  the  silent  areas,  there 
will  be  no  localizing  symptoms;  but  if  a  region  is  involved 
whose  function  is  definitely  known,  there  will  be  the  evi- 
dences of  suspended  function  of  the  part.  Unless  the  lacer- 
ation is  extensive,  with  considerable  extravasation  of  blood, 
there  will  be  no  evidences  of  compression. 


INJURIES  OF  CRANIAL  NERVES. 

Injuries  of  the  nerves  are  followed  by  a  temporary  or  per- 
manent paralysis  of  the  muscles  which  the  affected  nerves 
supply;  the  paralysis  is  located  on  the  same  side  of  the 
body  as  that  on  which  the  lesion  exists,  and  thereby  differs 
from  a  paralysis  due  to  injuries  of  the  motor  and  sensory 
nerve  centres  which  occasion  symptoms  on  the  opposite 
side.  (An  exception  to  the  latter  is  found  in  patients  whose 
medullary  motor  decussation  does  not  take  place.) 

Injuries  of  the  first  pair  of  cranial  nerves  result  in  loss  of 
smell.  Such  injuries  are  often  associated  with  lesions  of 
the  third  inferior  frontal  convolution  (Broca's  centre),  which 
occasion  motor  aphasia. 

Injuries  of  one  of  the  second  pair  of  cranial  nerves  result 
in  complete  blindness  on  the  affected  side. 

Injuries  of  the  third  nerve  result  in  ptosis  and  slight  ex- 
ophthalmos; the  eyeball  cannot  be  moved  upward,  down- 
ward, or  inward.  The  eye  deviates  outward  and  somewhat 
downward.  The  pupil  is  dilated  and  immobile,  and  accom- 
modation is  paralyzed. 


INJUIilES   OF    THE   HEAD  69 

Injuries  ot"  the  fourth  nerve  occasion  limitation  of  move- 
ment of  eyeball  downward  and  toward  the  paralyzed  side, 
and  diplopia  on  attempting  to  look  down.  The  eye  is 
deviated  upward  and  slightly  inward. 

Injuries  of  the  fifth  nerve  rarely  occur  alone.  They  re- 
sult in  anaesthesia  of  the  face  and  cornea,  paralysis  of  the 
masseter,  pterygoids,  and  temporal  muscles. 

Injuries  of  the  sixth  nerve  occasion  limitation  of  move- 
ment of  eyeball  outward  and  diplopia. 

Injuries  of  the  seventh  nerve  occasion  complete  paralysis 
of  the  muscles  of  the  face,  soft  palate,  and  orbicular  muscles 
of  mouth  and  eye.  The  face  is  flat  on  the  affected  side,  the 
angle  of  the  mouth  droops,  and  the  eyelids  cannot  be 
closed;  if  the  patient  is  asked  to  smile  or  show  his  teeth 
the  face  is  drawn  to  the  sound  side;  if  he  tries  to  swallow 
fluids,  these  run  out  of  the  angle  of  the  mouth  on  the  para- 
lyzed side.  If  the  soft  palate  is  not  paralyzed,  the  lesion  is 
below  the  geniculate  ganglion  of  this  nerve. 

Injuries  of  the  eighth  nerve  are  usually  associated  with 
basilar  lesions  of  the  facial,  and  result  in  deafness  on  one 
side. 

Injuries  of  the  ninth,  tenth,  eleventh,  and  twelfth  nerves 
are  rarely  found  alone.  Injuries  of  the  twelfth  would  result 
in  paralysis  of  one-half  of  the  tongue,  which  would  cause  it 
to  deviate  toward  the  paralyzed  side  when  it  is  protruded 
from  the  mouth. 

The  coma  resulting  from  cerebral  injuries  must  be  differ- 
entiated from  that  due  to  opium  poisoning,  diabetes,  neph- 
ritis, alcoholism,  apoplexy,  epilepsy,  hysteria,  and  asphyxia. 

The  coma  of  opium  poisoning  is  attended  by  very  slow 
respiration,  small  rapid  pulse,  and  extreme  contraction  of 
the  pupils.  The  coma  is  not  as  deep  as  that  from  cere- 
bral compression,  and  there  are  never  unilateral  symptoms  of 
paralysis  or  loss  of  corneal  or  tendon  reflexes. 

The  coma  of  diabetes  is  characterized  by  a  smell  of  ace- 
tone in  the  breath  and  perspiration,  and  by  the  presence  of 
considerable  sugar  in  the  urine. 

The  coma  of  nephritis  is  usually  preceded  by  convulsions, 
and  is  characterized  by  a  urinary  odor  of  the  breath, 
oedema  of  the  legs,  ascites,  and  a  diminution  in  the  quan- 


70     INJURIES  AND   DISEASES  OF   HEAD   AND   NECK 

tity  of  urine  excreted  by  the  kidneys.  The  urine  may  be 
bloody,  is  of  high  specific  gravity,  and  is  loaded  with  albu- 
min and  casts.  In  neither  diabetic  nor  ursemic  coma  are 
there  any  unilateral  paralyses. 

Alcoholic  coma  is  not  as  deep  as  that  after  severe  cerebral 
injuries.  The  individual  can  usually  be  aroused,  and  there 
is  an  alcoholic  odor  to  the  breath.  The  dirty  appearance, 
the  maudlin  resistance,  delirium,  and  restlessness  of  the 
patient  strongly  suggest  alcoholism.  There  are  no  unilateral 
symptoms. 

It  is  to  be  remembered  that  a  cranial  injury  may  have 
been  sustained  by  an  alcoholic  patient  or  by  one  who  is  a 
diabetic  or  nephritic;  in  all  cases  of  doubt  the  individual 
should  be  carefully  watched  and  repeatedly  examined. 

In  epileptic  coma  the  onset  is  preceded  by  a  cry,  biting 
of  the  tongue,  and  general  convulsion.  An  epileptic's 
tongue  is  scarred,  and  there  are  usually  scars  upon  the  head 
and  extremities  as  evidences  of  prior  attacks.  The  coma  is 
not  very  deep,  the  individual  can  be  aroused,  and  then  shows 
no  signs  of  paralysis.    The  pupils  are  equally  dilated. 

In  apoplectic  coma  the  arterial  pressure  is  very  high  and 
the  arteries  are  rigid;  the  respirations  are  stertorous.  Apo- 
plexy is  frequent  in  those  of  thick-set  stature  and  in  syphil- 
itics.  The  unilateral  paralyses  which  go  with  this  condition 
make  the  differential  diagnosis  very  difficult. 

In  all  doubtful  cases  it  should  be  the  rule  to  observe  the 
patient  for  twenty-four  hours  or  more. 


LOCALIZATION  OF  CEREBRAL  LESIONS. 

Every  patient  who  has  met  with  a  cranial  injury  should 
be  carefully  examined  for  focal  symptoms.  Thus  the  func- 
tional power  and  activity  of  the  muscles  of  the  face  and  eye, 
the  tongue,  and  of  the  extremities  should  be  individually 
determined;  the  sensibility  of  the  skin  to  touch,  to  heat,  and 
cold  should  be  tested;  the  condition  of  the  reflexes  should 
be  ascertained.  Tests  should  be  made  of  the  visual  fields 
of  both  eyes,  and  for  the  various  forms  of  aphasia;  and 
cranial-nerve  lesions  should  be  examined  for. 


ry JURIES  OF   THE   HEAD 


71 


Hemiplegia. — Ilemiplegia  (paralysis  of  one  side  of  the 
body)  or  convulsions  of  the  muscles  of  one  side  of  the  l)ody, 
point  respectively  to  destructive  and  irritative  lesions  of 
the  motor  area  of  the  opposite  side  of  the  brain — i.  e.,  the 
ascending  parietal  and  frontal  convolutions  of  the  cortex. 
In  this  area  the  face  is  represented  in  the  lowest  part,  the 
upper  extremity  and  trunk  in  the  middle  section,  and  the 
lower  extremity  in  the  uppermost  portion. 


Fig.  18 
Ant.  central  gyrus. 


Prevent) al  <iulcus. 
Sup.  frontal  sulcus    ^ 
Sup.  frontal  qyrus 

Middle  frontal  gt/i  u 

Inf.  frontal  sulcn 

Inf.  frontal  gyrni 

Ant.  limb  of  Jis.ui 
of  Sylvius. 

Post,  limb  of  fissuie 
of  Sylvius.  / 


Opercnlu 
Sup.  temporal  gyru 

\(l(Ve  temporul  nvriii 


Central  sulcus 
{fissure  of  Rolando). 

Po.'it-central  convohition. 
ipanetal  sulcus, 
upiuma)  <iinal  gyrus, 
uj)  jiniietitl  lubule.    ^ 
Ini  pa  I  lefal  lobule. 
ri''SU)e     of    Sylvius 
iis(  ending  ramus  of 
postenor  limb). 
Pa  rido- occipital 

fissure. 
Aniiuliir  gyrus. 

Suj)    occipital  lobe. 

Med   occipital  labr 
I  III}    occipital  lobe: 


Sup.  temporal  sulcus. 
Middle  temporal  sulcus. 


Inf.  temporal  gyrus\ 
Lateral  view  of  brain,  showing  fissures  and  convolutions.     (Vou  Bergniann.) 

Hemiplegia  may  also  follow  lesions  in  the  internal  cap- 
sule of  the  opposite  side,  lesions  in  the  crus  cerebri  of  the 
opposite  side,  lesions  in  the  pons  of  the  opposite  side,  and 
lesions  in  the  medulla  oblongata  of  the  opposite  side. 

Lesions  of  the  cortex  necessary  to  produce  complete  hemi- 
plegia must  be  more  extensive  than  similar  lesions  of  the 


72     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

capsule,  pons,  or  medulla.     From  the  extent  of  the  cere- 
bral motor  area  it  follows  that  hemiplegia  due  to  cortical 

Fig.  19 


The  functional  areas  of  the  cerebral  cortex.    Left  hemisphere.    (Starr.) 
Fig.  20 


The  functional  areas  of  the  cerebral  cortex.    Right  hemisphere.    (Starr.) 


INJURIES   OF   THE   HEAD 


73 


lesions  frequently  commences  in  the  arm  or  leg  or  face,  and 
spreads  with  more  or  less  rapidity  to  the  entire  half  of  the 
body.  With  lesions  of  the  internal  capsule,  crus  cerebri, 
pons  or  medulla,  the  paralysis  usually  involves  the  entire 
half  of  the  body  from  the  very  onset. 


Fig.  21 


Craniometer.    (Von  Bergmann.) 


In  hemiplegia  due  to  lesions  in  the  internal  capsule,  the 
muscles  supplied  by  the  upper  branches  of  the  facial  nerve 
and  the  back  muscles  are  usually  not  involved. 

If  in  addition  to  the  hemiplegia  there  is  also  hemianses- 
thesia  and  vasomotor  disturbances,  the  lesion  is  usually 
located  in  the  posterior  portion  of  the  internal  capsule. 


74     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Hemiplegia  due  to  lesions  of  the  cms  cerebri  is  always 
attended  by  paralysis  of  the  muscles  supplied  by  the  third 
foculomotor)  nerve  (see  p.  77)  of  the  side  opposite  to  the 
hemiplegia. 

Hemiplegia  due  to  lesions  of  the  'pons  is  usually  associated 

Fig.  22 


Craiiiometer.    (^'o^  Bergmaiiii.) 


with  paralysis  of  the  fifth,  sixth,  seventh,  and  twelfth  nerves 
of  the  side  opposite  to  the  hemiplegia. 

Hemiplegia  due  to  lesions  of  the  bulb  of  the  medulla  ob- 
longata is  associated  with  hemianesthesia  of  the  other  side 
of  the  body.  Hemiplegia  of  one  side  and  hemian?esthesia 
of  the  other  is  termed  "alternating  hemiplegia." 


INJURIES   OF   THE   HEAD  75 

It  is  to  be  remembered  that  although  the  paralysis  from 
these  several  lesions  usually  involves  the  side  of  the  body 
opposite  to  that  on  which  the  injury  has  been  sustained,  yet 
it  may  affect  the  muscles  of  the  same  side,  either  because 
the  paralyzing  factor  is  a  contre-cowp  injury — e-g.,  contre- 
coup  rupture  of  the  middle  meningeal  artery — or  because  the 
motor  tracts  do  not  decussate  in  the  medulla. 

Hemiansesthesia. — Hemiantesthesia  and  loss  of  muscle 
sense,  with  some  ataxia  of  one-half  of  the  body,  are  due  to 
lesions  of  the  cortical  sensory  centre  of  the  opposite  side  of 
the  brain,  or  to  lesions  of  the  internal  capsule  (posterior 
portion),  crura  cerebri,  pons,  or  medulla  oblongata.  The 
cortical  sensory  centre  overlaps  the  posterior  portion  of  the 
motor  area  and  extends  a  little  farther  backward.  The 
points  mentioned  above  for  locating  the  site  of  the  lesion  in 
hemiplegia  apply  for  the  localization  of  the  lesion  producing 
hemiansesthesia. 

Hemianopsia. — Hemianopsia,  blindness  of  one-half  of 
the  visual  field,  is  due  (1)  to  lesions  of  the  cuneus  and  upper 
part  of  the  occipital  lobe,  or  (2)  to  lesions  of  the  optic  tract 
behind  the  decussation  (chiasm)  of  the  same  side  as  the 
blind  halves  of  the  retina. 

Cortical  lesions  producing  hemianopsia  are  usually  asso- 
ciated with  psychical  or  central  mind  blindness,  in  which 
condition  visual  sensations  fail  to  summon  forth  any  recol- 
lection of  objects  or  circumstances  acquired  through  pre- 
vious education. 

Lesions  of  the  optic  tract  producing  hemianopsia  are 
usually  associated  with  paralyzing  symptoms  of  the  oculo- 
motor, trochlear,  and  trigeminal  nerves  of  the  same  side  as 
the  blind  halves  of  the  retina. 

With  hemianopsia  due  to  lesions  behind  the  geniculate 
bodies,  the  pupillary  light  reflex  is  present;  whereas  with 
lesions  in  front  of  the  geniculate  bodies  the  pupillary  light 
reflex  is  diminished  or  lost. 

Complete  blindness  in  one  eye  is  always  due  to  lesions  of 
the  optic  nerve  in  front  of  the  chiasm. 

With  absolute  hemianopsia — i.  e.,  loss  of  light,  form,  and 
color  sense — the  lesion  is  more  extensive  than  in  relative 
hemianopsia    (hemichromatopsia),   in    which   condition   the 


76     INJURIES  AND   DISEASES  OF   HEAD  AND  NECK 

light  sense  is  present,  but  the  form  and  color  senses  are 
lost. 

Nystagmus. — Nystagmus  and  paralysis  of  some  of  the 
ocular  muscles  in  both  eyes,  resulting  in  loss  of  co-ordinated 
movement  of  eyeballs,  together  with  a  staggering  gait  similar 
to  that  seen  in  cerebellar  disease  point  to  lesions  in  the 
corpora  quadrigemina. 

Aphasia.— Motor  aphasia — i.  e.,  the  inability  to  speak 
voluntarily,  or  to  repeat  words  one  after  the  other — is  due 
to  lesions  of  the  third  inferior  frontal  convolution  and  its 
association  tracts  of  the  left  side  in  right-handed  individuals, 
and  of  the  right  side  of  left-handed  ones. 

Word  deafness,  or  auditory  aphasia — i.  e.,  the  inability  to 
recall  the  spoken  name  of  objects  seen  or  heard  or  felt  or 
tasted,  or  to  understand  speech  and  musical  tunes,  or  to  call 
to  mind  the  objects  named — is  due  to  lesions  of  the  posterior 
two-thirds  of  the  upper  temporal  convolution  and  its  asso- 
ciation tracts. 

Word  blindness,  or  visual  aphasia — i.  e.,  the  inability  to 
understand  printed  or  written  words  or  to  recall  objects 
the  names  of  which  are  seen,  or  to  write  spontaneously,  or  to 
write  the  names  of  objects  seen,  heard,  etc.,  or  to  copy  and 
to  write  at  dictation,  or  to  read  understandingly  what  has 
been  written — is  due  to  lesions  of  the  angular  gyrus  and  its 
association  tracts. 

Ataxia. — Cerebellar  ataxia,  characterized  by  a  staggering 
gait,  dizziness,  and  buzzing  in  the  ears,  is  especially  found 
after  lesions  of  the  cerebellar  worm.  These  symptoms  are 
also  present  after  injuries  to  the  labyrinth,  and  in  fractures 
of  the  petrous  portion  of  the  temporal  bone.  With  such 
fractures  there  is  very  likely  to  be  paralysis  of  the  facial  and 
auditory  nerves. 

Rolling  and  rotation  of  the  body  around  its  long  axis,  with 
deviation  of  one  eye  upward  and  inward,  and  of  the  other 
downward  and  outward,  are  due  to  lesions  of  the  crura  cerebelli. 

Cheyne-Stokes  Breathing. — This  is  due  to  disturbed  func- 
tion of  the  respiratory  and  circulatory  centres  in  the  medulla. 

Traumatic  Diabetes. — Traumatic  diabetes,  polyuria,  and 
albuminuria  are  due  to  lesions  with  disturbed  function  of 
the  medulla. 


INJURIES  OF   THE  HEAD  77 

Implications  of  the  first  and  second  cranial  nerves  point 
to  lesions  in  the  anterior  cranial  fossa;  of  the  third,  fourth, 
fifth,  and  sixth  nerves,  to  the  middle  fossa;  of  the  seventh 
and  eighth  nerves  to  the  petrous  bone,  and  of  the  twelfth  to 
the  posterior  fossa. 


THE    DIAGNOSIS   OF    THE    NATURE    OF    TRAUMATIC 
LESIONS    OF    THE    SOFT   AND    BONY   CAPSULES. 

The  scalp  alone  or  the  bony  structure  as  well  may  be 
affected  by  the  traumatism.  Subcutaneous  linear  or  fissure 
fractures  of  the  vault  of  the  skull  without  depression  of  the 
fragments  cannot  be  made  out  by  palpation.  Symptoms  of 
compression  from  ruptured  vessels  or  from  laceration  of  the 
brain  cortex  point  rather  to  the  presence  of  such  fractures. 

Subcutaneous  fractures  with  depression  of  the  fragments, 
but  without  the  evidences  of  cerebral  compression,  must  be 
differentiated  from  deep  h?ematomata  of  the  scalp.  The 
margins  of  the  ridge  surrounding  a  hsematoma  of  the  scalp 
are  soft  and  can  be  indented,  whereas  the  margins  of  the 
ridge  surrounding  a  depressed  fracture  have  the  very  oppo- 
site characteristics. 

Open  wounds  of  the  scalp  should  always  be  aseptically 
explored  with  the  finger  to  determine  the  presence  or  absence 
of  a  fracture. 

A  fracture  of  the  base  is  present  if  cerebrospinal  fluid  or 
brain  substance  is  discharged  from  the  nose  or  ear.  Cere- 
brospinal fluid  is  distinguished  from  serum  by  its  high  albu- 
min percentage,  by  its  high  percentage  of  sodium  chloride, 
and  in  contradistinction  to  serum  its  flow  continues  in  large 
quantities  for  days. 

Fractures  of  the  base  usually  cause  paralysis  of  one  or 
more  of  the  cranial  nerves.  The  discharge  of  blood  from 
the  nose,  ear,  or  mouth,  or  an  extravasation  of  blood  beneath 
the  conjunctiva  or  beneath  the  scalp  in  the  mastoid  region, 
with  paralysis  of  one  or  more  of  the  cranial  nerves,  speaks 
strongly  for  fracture  of  the  base  of  the  skull. 

Middle  meningeal  hemorrhage,  with  evidences  of  com- 
pression, is  usually  a  complication  of  fracture  of  the  base. 


CHAPTER   VL 

INFLAMMATIONS  AND  NEOPLASMS  OP  THE  BRAIN 
AND  ITS  MEMBRANES. 

MENINGITIS. 

If  a  patient  with  an  infected  scalp  wound  or  compound 
fracture  of  the  skull  develops  gradually,  three  or  four  days 
after  an  injury  has  been  sustained,  a  rise  of  temperature  to 
101°  to  104°,  a  slow  pulse,  headache,  restlessness;  hyper- 
esthesia to  light,  sound,  and  touch;  grinding  of  the  teeth, 
and  muscular  twitchings,  and  then  a  paralysis  of  the  arm 
or  leg  or  entire  half  of  the  body,  depending  upon  the  area 
which  is  first  affected,  with  increasing  stupor,  irregular 
respirations,  and  increasing  pulse  rate,  we  are  safe  in  assum- 
ing that  he  has  a  cortical  meningitis.  If,  instead  of  the 
paralysis  of  the  arm  or  leg  or  entire  half  of  the  body,  the 
patient  shows  paralysis  of  the  muscles  supplied  by  the 
cranial  neryes,  especially  of  the  second,  third,  fourth,  sixth, 
seventh,  and  eighth,  with  marked  rigidity  of  the  neck,  we 
are  equally  safe  in  assuming  that  he  has  a  basilar  menin- 
gitis. 

A  meningitis,  however,  may  follow  other  conditions  than 
infected  wounds  of  the  scalp  or  skull — e.  g.,  sinus  thrombosis, 
abscess  of  the  brain,  suppuration  of  the  mastoid  cells,  tho- 
racic suppurations,  etc.;  and  we  should  be  prepared  to  inter- 
pret the  clinical  manifestations  above  mentioned  when  they 
arise  in  the  course  of  any  of  these  maladies. 

Should  we  be  in  doubt  about  the  diagnosis  we  have  in 
lumbar  puncture  and  McE wen's  sign^ — i.  e.,  a  changed 
percussion  note  over  the  parietal  regions — valuable  aids  in 
dispelling  our  uncertainty. 

Lumbar  puncture  in  meningitis  yields  a  cloudy  or  purulent 
fluid   containing  flocculi  of   fibrin,  polynuclear  leukocytes, 

1  See  p.  80, 


INFLAMMATIONS  AND  NEOPLASMS  OF   THE   BRAIN     79 

pus,  and  micro-organisms.  Cultures  of  the  fluid  will  deter- 
mine the  nature  of  the  infecting  organism,  whether  strepto- 
coccus, staphylococcus,  etc. 

ACUTE  SUPPURATIVE  ENCEPHALITIS. 

Should  an  acute  suppurative  encephalitis  develop  sec- 
ondarily to  an  infected  wound  of  the  scalp  or  a  depressed 
fracture  of  the  skull  with  laceration  of  the  brain,  without 
a  diffuse  purulent  leptomeningitis,  its  evidences  would  not 
be  manifested  until  ten  to  fourteen  days  after  the  injury; 
then  there  would  be  a  profuse  discharge  from  the  wound, 
the  scalp  would  be  swollen  and  oedematous,  and  the 
granulations  would  have  a  yellowish  color.  Retention  of 
pus  within  the  brain  would  be  followed  by  fever,  head- 
aches, and  possibly  vomiting.  If  the  abscess  occupies  an 
area  whose  function  is  known,  there  will  be  focal  symp- 
toms from  this  part — e.  g.,  hemiplegia,  hemianesthesia, 
hemianopsia,  etc.  (See  pp.  70-77.)  The  later  period  at 
which  symptoms  develop,  and  the  lesser  intensity  of  these 
latter,  differentiate  acute  suppurating  encephalitis  from 
purulent  meningitis.  It  should  be  noted,  however,  that 
purulent  meningitis,  as  a  rule,  coexists  with  an  acute  sup- 
purative encephalitis  and  masks  the  symptoms  which  the 
latter  occasions. 

CHRONIC  SUPPURATIVE  ENCEPHALITIS. 

A  chronic  suppurative  encephalitis  may  likewise  follow 
injuries  to  the  head  and  also  a  number  of  other  conditions 
— e.  g.,  chronic  suppuration  of  the  middle  ear,  mastoid, 
nasal  and  orbital  cavities,  suppuration  and  gangrene  of 
the  lung,  malignant  endocarditis,  and  some  of  the  acute 
infectious  diseases  such  as  typhoid  fever,  cerebrospinal 
meningitis,  etc.  Its  presence  is,  as  a  rule,  readily  deter- 
mined, but  its  localization  is  attended  with  much  greater 
difficulty,  as  its  most  frequent  sites  are  in  the  temporal  lobe 
and  cerebellum,  the  function  of  which  is  not  as  yet  well 
undei'stood. 


80     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Very  suggestive  of  the  formation  of  a  cerebral  abscess 
after  suppurative  otitis  media  is  the  cessation  of  the  ear 
discharge,  with  a  sudden  fall  of  temperature,  the  patient 
continuing  to  feel  ill  and  having  indefinite  cerebral  symptoms. 

The  cerebral  symptoms,  which  are  the  same  in  all  cases  of 
chronic  abscess,  no  matter  what  their  causation  is, consist  of  an 
altered  mental  character  of  the  individual;  he  is  irritable, 
dull,  or  stupid,  and  suffers  from  malaise.  His  temperature 
varies;  it  may  be  persistently  low  with  little  variation  or 
there  may  be  occasional  chilliness  or  even  a  distinct  chill 
with  rise  of  temperature.  The  appetite  is  poor  and  the 
bowels  are  apt  to  be  constipated.  After  a  shorter  or  longer 
duration  of  these  indefinite  cerebral  symptoms^  the  mental 
stupor  increases  and  alternates  with  irritability  and  restless- 
ness. Headaches,  irregular  temperatures,  vomiting,  and 
general  septic  appearances,  together  with  the  evidences  of 
increased  cerebral  tension,  develop.  These  last  are  Mc- 
Ewen's  sign,^  an  inconstantly  occurring  optic  neuritis,  a 
slow  pulse,  headache  which  is  sometimes  located  over  the 
seat  of  the  abscess,  and  tenderness  of  the  head  to  percussion. 
This  period  is  termed  the  active  period  of  the  abscess  and 
at  this  stage  it  must  be  differentiated  from  acute  menin- 
gitis and  thrombosis  of  the  lateral  sinus. 

In  acute  meningitis  the  onset  and  course  are  more  rapid, 
there  is  marked  hypersesthesia  to  sound,  light,  and  touch; 
the  temperature  is  higher,  from  101°  to  104°;  the  pulse, 
though  slow  at  the  onset,  becomes  rapid  and  irregular;  there 
are  muscular  twitchings,  spasms,  convulsions,  strabismus, 
and  pain  and  rigidity  of  neck.  In  doubtful  cases,  lumbar 
puncture  will  aid  in  making  the  diagnosis;  for  in  meningitis 
the  spinal  fluid  is  turbid  and  contains  pus  cells  and  bac- 
teria, whereas  in  cerebral  abscess  it  is  usually  clear.  In 
meningitis  there  is  no  choked  disk. 

In  thrombosis  of  lateral  sinus  the  temperature  is  high, 
and  with  the  breaking  up  of  the  infected  thrombus  in  the 

1  This  period  is  known  as  the  latent  period  of  cerebral  abscess. 

2  Normally  the  percussion  note  which  is  elicited  with  a  rubber-tipped  percussion 
hammer  over  the  temporo-parietal-frontal  region,  while  the  patient  is  sitting  up  is 
dull,  but  with  increased  cerebral  tension  it  changes  to  a  higher-pitched  and  more 
resonant,  almost  tympanitic  note,  the  resonance  increasing  as  the  tension  rises, 


INFLAMMATIONS  AND  NEOPLASMS  OF   THE  BRAIN     81 

sinus  and  metastatic  lodgement  of  the  infected  fragments 
in  the  internal  organs  there  are  frequent  chills  and  fluc- 
tuating temperatures  between  97°+  and  109° — .  There  are 
apt  to  be  mastoid  tenderness,  tenderness  over  the  jugular, 
venous  congestion  of  the  scalp,  and  possibly  exophthalmos. 
Choked  disk  is  an  early  symptom. 

Localization  of  the  Abscess. — As  is  said  above,  it  is 
not  always  possible  to  locate  the  site  of  the  abscess.  It  is 
well  to  remember  that  after  an  injury  the  abscess  may  form 
superficially  in  the  cortex  at  the  site  of  the  injury  or  it  may 
develop  in  the  deeper  parts;  and  that  after  otitis  media  the 
abscess,  as  a  rule,  is  in  the  temporal  lobe  if  the  primary  site 
of  suppuration  is  at  the  tegmen  tympani  or  in  the  anterior 
mastoid  cells;  while  if  the  primary  suppuration  is  in  the 
posterior  mastoid  cells  or  on  the  posterior  wall  of  the  middle 
ear,  the  abscess  is  likely  to  be  in  the  cerebellum. 

Abscesses  in  the  temporal  lobe,  according  to  Freund  and 
Pick  and  Starr,  frequently  give  rise  to  "optical  aphasia,"  a 
condition  in  which  the  patient  cannot  name  the  object  which 
he  sees.  He  can  understand  and  recognize  the  name,  can 
talk  and  describe  the  object,  can  repeat  the  name,  and  may 
even  be  able  to  name  the  object  if  he  is  permitted  to  touch 
or  taste  or  smell  it. 

Abscesses  in  the  internal  capsule  cause  hemiplegia,  hemi- 
ansesthesia,  hemianopsia  of  the  opposite  sides. 

Cerebellar  abscesses  cause  vertigo,  staggering  gait  (usually 
to  the  side  on  which  the  abscess  lies),  vomiting,  diplopia, 
nystagmus.  If  the  abscess  presses  upon  one  side  of  the 
pons  and  medulla,  paralysis  of  the  sixth  and  seventh  cranial 
nerves  results. 

ASEPTIC  SINUS  THROMBOSIS. 

The  diagnosis  of  aseptic  cranial  sinus  thrombosis  is  re- 
servedly made  when,  after  a  long-continued  diarrhoea  or 
exhausting  illness,  such  as  carcinoma,  pulmonary  phthisis, 
etc.,  an  individual  suddenly  commences  to  suffer  with  a 
unilateral  headache,  delirium,  and  somnolence.  As  the 
superior  longitudinal  sinus  is  the  one  that  is  usually  throm- 
bosed in  this  way,  the  diagnosis  is  materially  strengthened 


82     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

if  there  develops  venous  stasis  and  oedema  of  the  frontal 
and  parietal  veins,  distention  of  the  veins  of  the  orbit  and 
eye,  and  nose-bleed. 


INFECTIVE  SINUS  THROMBOSIS. 

The  recognition  of  aseptic  sinus  thrombosis  is  chiefly 
important  to  us  as  regards  prognosis.  It  does  not  influence 
our  therapy,  for  thus  far  no  one  has  deemed  it  wise  to  inter- 
fere surgically  to  relieve  the  thrombosed  sinus.  Far  different 
is  it  in  infective  sinus  thrombosis,  for  here  we  can  do  a  great 
deal  by  surgical  measures ;  and  if  we  would  afford  the  patient 
the  life-saving  benefits  of  operation,  we  must  make  the 
diagnosis  before  the  'manifestations  of  pysemia  or  deep 
septic  intoxication  develop;  and  it  is  not,  in  the  majority  of 
cases,  difficult  to  make  such  an  early  diagnosis.  Given  a 
cause  for  sinus  involvement,  such  as  mastoid  disease,  ery- 
sipelas of  the  scalp,  infected  wounds  of  the  scalp,  or  sup- 
puration in  the  nose,  middle  ear  or  orbit,  a  high  rise  of 
temperature  to  104°  or  over,  with  or  without  a  chill  and 
headache  and  vomiting,  should  be  viewed  with  great  sus- 
picion and  the  possibilities  of  sinus  thrombosis  should  be 
borne  in  mind;  and  especially  are  such  symptoms  significant 
if  a  carefully  made  physical  examination  of  all  the  other 
organs  or  a  thorough  inspection  of  the  wound  fails  to.  reveal 
a  cause  for  them. 

The  addition  of  increasing  delirium,  stupor,  and  vertigo, 
of  focal  symptoms,  such  as  hemispasms,  paralysis,  aphasia,  or 
some  affection  of  the  cranial  nerves  from  the  irritation  and 
compression  exerted  by  the  inflamed  thrombosed  sinus  upon 
the  immediately  surrounding  nerves  and  brain  centres,  and  of 
local  evidences  in  the  superficial  or  jugular  veins  into  which 
the  thrombosis  has  extended,  such  as  painful  oedema,  local 
tenderness  and  abscess  formation  of  the  superficial  soft  parts, 
emptiness  of  the  veins  proximally  to  the  thrombosis  and  dis- 
tention distally  to  it,  naturally  make  the  diagnosis  much  more 
certain.  Absolute  certainty  of  diagnosis,  as  far  as  such  a  thing 
is  possible  in  dealing  with  diseased  conditions,  is  attained  when 
the  softening  and  disorganization  of  the  thrombus  permits 


INFLAMMATIONS  AND  NEOPLASMS  OF   THE  BRAIN     83 

infected  portions  thereof  to  be  carried  into  the  general  cir- 
culation and  lodged  in  other  viscera,  with  the  resulting  con- 
stitutional and  local  manifestations  of  pyaemia.  With  each 
lodgement  there  is  a  chill  and  rise  of  temperature  to  105°- 
108°,  followed  by  a  fall  of  temperature  below  the  normal, 
and  a  profuse  sweat.  Such  chills  and  fluctuations  of  tem- 
perature have  no  regularity;  they  may  occur  once  or  several 
times  a  day,  or  every  other  day  or  once  in  several  days.  In 
the  organs  in  which  the  infected  emboli  have  lodged  there 
are  the  signs  of  metastatic  abscesses.  But  not  in  all  cases 
are  these  pysemic  symptoms  manifested;  instead  the  tem- 
perature in  some  cases  remains  continuously  high,  there  is 
a  profuse  septic  diarrhoea,  septic  roseola  and  rash,  and  an 
enlarged  spleen.  It  is  in  these  latter  cases  especially  that 
the  differential  diagnosis  from  typhoid  fever  is  very  difficult. 

Localization  of  Affected  Sinus. — The  location  of  the 
thrombosed  sinus  is  determined  from  the  site  of  the  exciting 
cause  thereof,  from  focal  brain  symptoms,  and  from  local 
evidences  in  the  superficial  soft  parts. 

With  sigmoid  sinus  thrombosis  there  is  a  circumscribed 
painful  oedema  along  the  posterior  border  and  apex  of  the 
mastoid  process,  occasionally  a  subperiosteal  abscess  at 
the  site  of  the  mastoid  vein,  or  a  deep  abscess  in  the  sub- 
occipital fossa  corresponding  to  the  condyloid  vein;  swelling 
and  thrombosis  of  the  internal  jugular  vein,  which  can  be 
felt  as  a  hard  tender  cord,  and  which  occasions  pain  and 
torticollis  (the  patient  holding  the  head  toward  the  affected 
side  to  avoid  the  pain).  Unusual  emptiness  of  this  vein  in 
virtue  of  its  thrombosis  (especially  to  be  detected  in  deep 
inspiration),  swelling  of  the  cervical  glands,  and  hoarseness, 
dyspnoea,  slow  pulse,  difficulty  in  swallowing,  and  spasm  of 
the  sternocleidomastoid  and  trapezius  muscles,  from  com- 
pression of  the  ninth,  tenth,  and  eleventh  cranial  nerves  in 
the  jugular  foramen,  are  sometimes  present.  Nystagmus 
is  sometimes  present,  and  choked  disk  occurs  in  50  per  cent, 
of  the  cases. 

With  cavernous  sinus  thrombosis  there  is  oedema  and 
swelling  with  venous  congestion  in  the  face  and  about  the 
eye,  nasal  hemorrhage,  exophthalmos,  and  distention  of  the 
retinal   veins,    and   from   compression   of   the   oculomotor, 


84     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

trochlear,  abducens,  and  first  division  of  the  fifth  nerves 
there  will  be  pain  in  the  frontal  and  supraorbital  regions, 
ptosis  of  the  upper  lid,  various  forms  of  strabismus,  and 
cloudy  and  sometimes  softened  cornea.  If  these  symptoms 
also  appear  on  the  opposite  side  it  indicates  that  the  process 
has  extended  from  the  sinus  of  the  one  side  to  that  of  the 
other. 

With  superior  petrosal  and  superior  longitudinal  sinus 
thrombosis  there  are  no  especial  local  symptoms.  With 
the  latter  there  is  at  times  venous  congestion  of  the  entire 
cranium,  including  the  orbit  and  the  eye,  and  nose-bleeds. 

With  transverse  sinus  thrombosis  there  are  no  local  symp- 
toms unless  the  clot  extends  into  the  bulb  of  the  jugular,  and 
then  there  may  be  evidences  of  compression  of  the  ninth, 
tenth,  and  eleventh  nerves. 

At  its  beginning  infective  sinus  thrombosis  may  give  one 
the  impression  of  a  chronic  brain  abscess  in  its  active  period; 
but  a  brain  abscess  rarely  occasions  such  high  temperature, 
and  never  is  attended  with  pysemic  temperature.  In  some 
cases  sinus  thrombosis  and  brain  abscess  coexist;  in  such 
instances  a  diagnosis  of  brain  abscess  can  only  be  made  if 
there  are  focal  symptoms.  If  in  a  case  of  sinus  thrombosis 
the  symptoms  are  not  relieved  after  incision  and  drainage 
of  the  infected  vein,  a  brain  abscess  should  be  suspected 
and  a  search  therefor  with  the  aspirating  needle  should  be 
made. 

The  patients  who  manifest  with  their  sinus  thrombosis  a 
continuously  high  temperature,  diarrhoea,  roseola,  and 
enlarged  spleen,  may,  as  stated  above,  be  suspected  of  hav- 
ing typhoid  fever;  but  a  slow  pulse,  a  low  leukocyte  count, 
and  a  Widal  reaction  in  the  serum  point  to  typhoid,  while 
the  presence  of  a  cause  for  sinus  thrombosis — e.  g.,  chronic 
otorrhoea — favors  the  existence  of  this  latter  condition.  The 
presence  of  tubercles  on  the  choroid,  the  rapid  respiration 
without  manifest  pulmonary  lesion,  and  the  existence  of  a 
primary  tuberculous  focus  in  the  bones,  joints,  lungs,  etc., 
similarly  distinguish  acute  miliary  tuberculosis  from  these 
forms  of  sinus  thrombosis. 

Maliffnant  endocarditis  and  malaria  bear  some  resem- 
blance  in  their  temperature  curve  and  frequently  occurring 


INFLAMMATIONS  AND  NEOPLASMS  OF   THE  BRAIN     85 

chills  to  the  pyiieinic  cases  of  sinus  thrombosis.  The  presence 
of  minute  petechifc  in  the  conjunctivae  and  skin,  the  history 
of  an  old  heart  lesion,  and  the  absence  of  a  cause  for  sinus 
thrombosis  readily  distinguish  the  endocardial  cases;  while 
the  regular  cycle  of  the  chills  and  fever  and  the  presence  of 
Plasmodia  in  the  blood  at  once  differentiate  malaria  from 
sinus  infection  and  thrombosis. 

It  is  a  frequent  but  unwise  practice  to  administer  quinine 
in  cases  in  which  a  malarial  infection  is  suspected,  for  in 
this  way  we  cloud  the  clinical  picture  by  changing  the 
temperature  curve.  It  is  better  to  wait  for  twenty-four 
hours  and  observe  the  course  of  the  temperatures  and  make 
repeated  examinations  of  the  blood  for  the  plasmodia  of 
malaria. 

INTRACRANIAL  NEOPLASMS. 

The  positive  evidence  of  the  presence  of  a  intracranial 
neoplasm  which  is  afforded  by  a  palpable  tumor  is  only 
obtainable  in  rare  instances,  and  that  when  a  growth  of  the 
meninges  has  eroded  and  protruded  through  the  cranial 
bones.  Our  diagnosis  of  an  intracranial  neoplasm  does  not, 
however,  depend  upon  the  palpation  of  a  tumor;  it  can  be 
made  from  characteristic  general  symptoms  to  which  such 
a  condition  gives  rise.  These  general  disturbances  are 
characterized  by  their  gradual  development  and  their  con- 
tinuous progression,  and  only  in  rare  cases  have  intracranial 
tumors  grown  to  any  size  without  having  given  rise  to  them. 

Symptoms. — The  general  symptoms  are: 

Headache;  this  is  either  frontal  or  occipital;  it  is  usually 
very  intense,  and  the  cause  of  much  suffering. 

It  is  most  constant  and  severe  with  neoplasms  in  the 
posterior  fossa  of  the  skull,  below  the  tentorium  cerebelli. 
Its  site  rarely  indicates  the  position  of  the  tumor. 

Tenderness  of  the  bone  to  percussion  at  the  site  of  the 
headache  may  aid  in  localizing  the  tumor,  unless  such  ten- 
derness is  due  to  the  irritability  of  a  single  superficial  nerve. 

Convulsions;  these  may  be  of  the  nature  of  petit  mal  or 
general  epileptic  seizures.  They  may  be  an  early  symptom, 
occur  once  and  never  be   repeated,  or  they  may  occur  at 


86     INJURIES  AND   DISEASES   OF  HEAD  AND  NECK 

irregular  intervals  during  the  course  of  the  disease,  at  times 
overshadowing  all  the  other  symptoms  so  that  the  disease  is 
considered  to  be  epilepsy. 

Vomiting  and  vertigo. 

Choked  disk,  or  optic  neuritis. 

Change  of  disposition  and  mental  power. 

Slow  pulse. 

Attacks  of  syncope,  polyuria,  and  progressive  malnutrition. 

These  general  symptoms  may  at  times  be  strongly  simulated 
by  those  which  are  occasioned  by  a  chronic  brain  abscess; 
but  the  latter  can  usually  be  traced  to  a  cranial  injury  or  to 
suppuration  of  the  middle  ear,  nasal  or  orbital  cavities. 
With  abscess  the  symptoms  appear  in  more  rapid  succes- 
sion, and  with  greater  severity;  and  they  are  more  apt  to  be 
attended  with  an  irregular  fever.  With  intracranial  tumor 
the  onset  of  symptoms  is  very  gradual,  but  they  increase 
steadily  in  intensity,  and  the  whole  course  of  the  malady 
is  longer.  Focal  symptoms  are  more  apt  to  be  present  with 
cerebral  neoplasms  and  likewise  optic  neuritis. 

The  symptoms  of  tuberculous  meningitis  bear  some 
resemblance  to  those  of  tuberculous  tumor,  but  with  the 
former  the  headache  is  more  severe  and  continuous;  there 
is  more  likely  to  be  hypersesthesia  to  light,  sound,  and  touch; 
optic  neuritis  is  less  likely  to  be  present,  and,  when  it  is,  it  is 
less  intense  and  later  in  its  appearance;  and  the  ophthalmo- 
scope may  show  the  presence  of  tubercles  upon  the  choroid. 
Should  there  remain  a  doubt  as  to  the  nature  of  the  malady, 
a  lumbar  puncture  will  aid  in  clearing  it  up,  for  in  meningitis 
such  puncture  frequently  yields  a  cloudy  fluid  which  con- 
tains tubercle  bacilli.^ 

A  localized  tuberculous  meningitis  can  seldom  be  differ- 
entiated from  a  tuberculous  tumor. 

Chronic  hydrocephalus  occasions  general  symptoms  that 
may  be  mistaken  for  those  due  to  neoplasm;  but  in  this 
malady  there  is  a  spastic  paralysis  without  any  focal  spasm, 
and  the  paralysis  is  always  bilateral,  the  lower  limbs  being 
more  affected  than  the  upper.  Cranial-nerve  paralyses 
are  late  manifestations.    Early  evidences  of  bilateral  spastic 

1  The  presence  of  the  hacilli  may  be  demonstrated  in  spreads,  or  by  culture. 


INFLAMMATIONS  AND  NEOPLASMS  OF   THE  BRAIN     87 

paralysis  and  late  cranial-nerve  paralysis  point  to  chronic 
hydrocephalus. 

The  presence  of  a  tumor  having  been  determined,  the 
next  query  is,  What  is  its  site?  This  is  ascertained  from  the 
focal  symptoms.  These  are,  as  a  rule,  unilateral;  they  com- 
mence gradually  and  spread  slowly.  ^Tien  they  are  due  to 
cortical  tumors  they  are  at  first  irritative  in  character  and 
later  on  paralytic;  but  when  they  are  occasioned  by  a  sub- 
cortical tumor  they  are  usually  paralytic  from  the  beginning. 
Depending  upon  the  site  of  the  neoplasms  these  focal  symp- 
toms will  be  unilateral  spasms,  monoplegia,  hemiplegia, 
parsesthesia  or  anaesthesia  in  one  or  more  limbs;  hemi- 
anopsia and  various  forms  of  aphasia,  and  affections  of  the 
cranial  nerves  and  basal  ganglia.  (For  localization  of  cere- 
bral function,  see  p.  70.)  Jackson  was  the  first  to  describe 
the  tonic  and  clonic  convulsions  which  occur  at  intervals, 
limited  to  one  part  of  the  body — e.  g.,  the  face,  or  hand, 
or  foot — and  sometimes  extending  from  the  part  first  in- 
vaded to  other  parts  of  the  body  in  a  definite  order  of 
succession — e.  g.,  from  the  face  to  the  arm,  to  the  trunk,  and 
then  to  the  leg.  Such  a  localized  convulsion  is  known  as  a 
Jacksonian  epilepsy.  The  spasm  always  begins  in  the  muscles 
which  are  represented  in  the  centre  first  irritated,  and  natu- 
rally the  determination  of  these  muscles  is  of  immense  aid 
in  the  localization  of  the  tumor. 

An  absence  of  focal  symptoms  points  to  the  frontal  or 
temporal  lobe  as  the  seat  of  the  neoplasm. 

The  nature  of  the  neoplasm  can  only  be  indefinitely  deter- 
mined. A  previous  history  of  syphilis  or  tuberculosis  and 
the  evidences  of  other  syphilitic  or  tuberculous  lesions  are 
naturally  very  suggestive  of  a  similar  lesion  in  the  brain 
and  its  membranes.  A  marked  or  complete  recovery  from 
antisyphilitic  treatment  is  indicative  of  a  syphilitic  tumor, 
,but  partial  improvement  is  not  to  be  so  considered,  for  a 
great  many  other  neoplasms  are  temporarily  and  partially 
improved  by  this  treatment.  A  variable  intensity  of  the 
symptoms  speaks  for  considerable  vascularity  of  the  tumor; 
hence  for  glioma,  gliosarcoma,  and  aneurysms.  A  primary 
carcinoma  in  some  other  organ  suggests  the  probability  of 
the  brain  neoplasm  being  a  metastatic  deposit. 


CHAPTER  VII. 

INJURIES,  INFLAMMATIONS,  AND   NEOPLASMS  OF  THE 

FACE. 

INFLAMMATIONS  AND  NEOPLASMS  OF  THE  SKIN. 

Of  neoplastic  and  chronic  inflammatory  affections  of  the 
skin,  it  is  necessary  to  consider  especially  only  the  lupoid, 
the  syphilitic,  and  the  epitheliomatous.  In  the  early  stages 
of  these  diseases  the  difi^erential  diagnosis  can  be  readily 
made,  but  in  the  advanced  stages,  when  ulceration  has  taken 
place,  their  differential  diagnosis  is  often  attended  with  some 
difficulty.  Considerable  aid  is  afforded  by  the  previous  per- 
sonal and  family  history  of  the  patient  (thus,  syphilis  and 
tuberculosis),  by  the  nature  of  the  early  manifestations  of 
the  malady,  and  by  a  careful  physical  examination  for  other 
evidences  of  tuberculous,  syphilitic,  or  malignant  disease. 
In  doubtful  cases  a  section  should  be  given  to  the  patholo- 
gist for  microscopic  examination. 

Lupus  Vulgaris. — Lupus  vulgaris  occurs  chiefly  in  young 
subjects.  It  first  appears  as  a  group  of  slightly  raised,  pin's- 
head  size  nodules  in  the  skin  or  mucous  membranes.  Very 
gradually  new  nodules  develop  around  the  first  group,  thus 
forming  an  elevated  mass  that  is  covered  with  thick  scales 
of  epidermis  and  that  soon  undergoes  ulceration.  The 
ulcer  may  eat  away  the  skin,  muscles,  and  mucous  mem- 
brane, but  never  involves  the  bone.  At  its  periphery  new 
discrete  nodules  are  always  to  be  seen.  As  the  ulcer  ad- 
vances it  tends  to  cicatrize  in  the  part  first  attacked.  This 
tendency  toward  cicatrization  in  one  part  and  advance- 
ment in  another  part  of  the  ulcer,  with  the  presence  of  dis- 
crete nodules  at  the  margins,  is  characteristic  of  lupus. 

The  Primary  Chancre  of  Syphilis.— This  is  most  fre- 
quently met  with  on  the  lips,  and  is  to  be  distinguished 
from  epithelioma  by  the  following  characteristics:  Its  first 
appearance  is  as  an  ulcer;    its  increase  in  size  is  rapid;  it 


INJURIES  AND   NEOPLASMS  OF   THE   FACE 


89 


occurs  in  younger  individuals,  and  it  is  followed  by  the 
evidences  of  constitutional  syphilis  in  three  to  four  weeks. 
In  doubtful  cases  a  section  should  be  given  to  the  patholo- 
gist for  microscopic  diagnosis. 

Ulcerating  Gumma. — The    ulcerating   gumma    appears 
first  as  a  discrete,  soft,  elastic  tumor;  the  ulcer  usually  has 


Fin.  23 


Cavernous  angiolipoma  of  side  of  face  and  ear.  Note  the  telangiectatic  condition 
of  the  skin  overlying  the  tumor,  which  was  soft  and  doughy  in  character  (lipoma) 
and  pulsated  markedly  (cavernous  angioma). 


undermined,  non-indurated,  serpiginous  edges.  There  are 
usually  other  evidences  of  syphilis  that  aid  us  in  making 
the  diagnosis. 

Epithelioma. — Epithelioma  of  the  face  is  met  with  in 
two  forms:  the  superficial  or  rodent  ulcer  type,  occurring 
chiefly  above  a  line  drawn  through  the  angles  of  the  mouth 
to  the  lobules  of  the  ear,  and  the  deep,  infiltrating  carcinoma, 


90     INJURIES  AND  DISEASES  OF   HEAD  AND  NECK 

which  originates  in  the  glands  of  the  cutis.     The  former 
commences  as  a  small  superficial  ulcer,  which  very  gradually 

Fig.  24 


Chancre  of  the  chin  ten  days  after  infection  by  a  cut  with  a  razor.    (Von  Bergmann.) 

Fig.  25 


i* 


± 


K    ' -' 


m 


\ 


Superficial  epithelioma  or  rodent  ulcer.    (Von  Bergmann's  clinic.) 


INJURIES  AND   NEOPLASMS  OF    THE  FACE  91 

extends  and  tends  to  cicatrize  in  some  of  its  parts.  The 
latter  appears  as  an  aggregation  of  deep-seated,  hard  nodules 
which  extend  rapidly,  invade  the  deep  structures,  even  the 
bones,  and  soon  break  down,  leaving  an  ulcer  with  everted, 
indurated  edges,  and  unhealthy,  easily  bleeding,  crusty  base. 
In  the  lower  lip  it  commences  as  a  crack  or  fissure  or  hard 
nodule  that  does  not  heal,  becomes  indurated,  increases  in 
size,  and  undergoes  ulceration. 

Fig.  26 


Deep,  infiltrating  epithelioma  of  the  lower  lip.    (Von  Bergmann.) 


INJURIES,    INFLAMMATIONS,    AND    NEOPLASMS    OF 
BONES  OF  FACE  AND  JAW. 

Fractures. — Fractures  of  the  facial  bones  give  the  usual 
evidences  of  such  injuries  and  require  no  especial  diagnostic 
consideration.  Fractures  of  the  lower  jaw  are  usually  com- 
pound and  are  easily  detected  by  the  step-like  irregularity 
they  occasion  in  the  alignment  of  the  lower  teeth.    Fractures 


92     INJURIES  AND   DISEASES  OF   HEAD   AND   NECK 

of  the  alveolar  margin  of  the  upper  jaw  cause  a  similar 
irregularity  in  the  alignment  of  the  upper  teeth. 

Dislocations. — Dislocation  of  the  lower  jaw  results  from 
opening  the  mouth  too  widely  and  is  pathognomonically 
indicated  by  an  inability  to  close  the  mouth.  If  both  tem- 
poromaxillary  joints  are  dislocated,  the  jaw  projects  directly 
forward  and  downward,  the  chin  being  very  prominent. 
If  only  one  of  these  joints  is  dislocated  the  lower  jaw  projects 
forward,  and  inclines  downward  on  the  affected  side.  Over 
the  dislocated  joint  there  is  a  decided  hollow. 


Fig.  27 


Fracture  of  the  jaw.    Note  the  step-like  irregularity  in  the  alignment  of  the  lower 
teeth.    (Von  Bergmann.) 


Suppurative  Inflammations. — An  acute  onset  of  severe 
constitutional  symptoms — i.  e.,  high  fever,  rapid  pulse,  stupor, 
and  delirium — combined  with  swelling,  pain,  and  exquisite 
tenderness  of  either  jaw-bone,  coming  on  after  the  extrac- 
tion of  a  tooth  or  a  compound  fracture  of  the  jaw,  are  almost 
pathognomonic  of  acute  infectious  osteomyelitis  of.  the 
maxillary  bones.  The  extremely  septic  character  of  these 
inflammations  is  to  be  especially  noted,  and  the  urgency  for 
immediate  operation  in  their  presence  is  to  be  borne  in 
mind. 

A  change  in  the  normal  outline  of  one  or  more  of  the  facial 
bones  due  to  irregular  thickening  of  their  periosteal  covering, 


INJURIES  AND  NEOPLASMS  OF   THE  FACE 


93 


and  the  presence  of  profusely  discharging  sinuses  leading 
down  to  bare  bone,  are  evidences  of  a  chronic  osteomyelitis. 
Such  a  chronic  osteomyelitis  may  result  from  caries  of  the 
teeth,  from  syphilis,  tuberculosis,  actinomycosis,  phosphorus 
poisoning,  mercurial  stomatitis,  etc.,  and  the  particular 
cause  in  each  case  is  to  be  determined  from  the  personal 
and  family  history,  from  the  site  of  the  disease  and  from 
the  especial  character  of  the  local  lesions.     Thus  a  history 


Fig.  28 


Osteomyelitis  of  tlie  lower  jaw.    (Von  Bergmann.) 

of  family  or  personal  tuberculosis  or  of  acquired  syphilis 
suggests  these  diseases  as  a  cause  for  the  osteomyelitis; 
syphilis,  furthermore,  most  frequently  attacks  the  nasal  and 
palatal  processes  of  the  superior  maxillary  bones;  tuber- 
culosis, the  orbital  margin  of  the  superior  maxilla,  and 
actinomycosis  the  ramus  of  the  lower  jaw. 

Phosphorus  necrosis  is  marked  by  the  presence  of  large, 
isolated,  periosteal  osteophytes,  by  considerable  retraction  of 
the  gums  with  exposure  of  the  necrotic  bone,  and  by  dropping 


94     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

out  of  the  teeth.  Actinomycosis  is  evidenced  by  the  marked 
involvement  of  the  soft  parts  of  the  cheek  and  submaxillary 
region,  the  lumpy  character  of  the  lesions  of  the  soft  parts, 
by  the  discharge  of  the  characteristic  pinhead,  yellowish 
granules  which  on  microscopic  examination  are  found  to 
contain  the  ray  fungus,  and  by  the  absence  of  glandular 
involvement  during  the  early  stages. 

Chronic  Hydrops. — A  uniform  distention  of  the  cavities 
of  the  frontal  and  maxillary  sinuses  with  such  thinning  of 


Periostitis  of  the  lower  jaw.    (Von  Bergmann.) 


their  walls  as  to  cause  these  to  crackle  under  the  palpating 
finger,  together  with  a  feeling  of  weight  and  oppression  in 
these  parts,  are  evidences  of  chronic  hydrops  of  these  sinuses. 

The  distention  is,  in  the  large  majority  of  cases,  not  due 
to  an  accumulation  of  mucoid  or  serous  fluid  in  the  sinus, 
but  results  from  the  presence  of  mucous  polypi  therein,  or, 
in  the  case  of  the  antrum  of  Highmore,  to  the  presence 
within  it  of  a  dentigerous  cyst. 

In  the  frontal  sinus  the  lower  or  orbital  wall  is  the  first 


INJURIES  AND  NEOPLASMS  OF   THE  FACE 


95 


to  protrude,  the  eyeball  being  displaced  outward  and  down- 
ward; the  anterior  and  inner  walls  subsequently  bulge  out- 
ward. In  the  maxillary  sinus — i.  e.,  the  antrum  of  High- 
more — the  anterior  wall,  especially  at  the  canine  fossa  and 
the  lower  and  inner  walls,  become  very  prominent  and  very 
thin,  the  gum  is  crowded  downward,  and  the  alveolar  process 
is  thickened.  The  thinning  of  the  walls  permits  a  feeling  of 
fluctuation  to  be  obtained  and  also  allows  of  transillumina- 


FtG.  30 


Chrouic  hydrops  of  the  right  antrum  of  Higbmore.    Note  the  bulging  of  the  cheelc 
and  the  exophthalmos  without  displacement  of  the  angle  of  thejmouth. 


tion  of  the  cavity  of  the  sinus.  The  unijorm  bulging  and 
thinning  out  of  the  walls  of  the  cavities,  together  with  the 
crackling  and  sense  of  fluctuation  which  are  to  be  elicited 
upon  palpation,  are  sufficient  to  establish  the  differentiation 
of  a  chronic  hydrops  from  tumors  of  these  bones. 

Thus  cysts  of  the  maxillary  bones  grow  only  in  one  direc- 
tion, either  upward  toward  the  antrum  or  nose,  or  downward 
toward  the  gums,  or  backward ;  they  do  not  cause  the  uniform 
bulging  of  the  walls  of  the  antrum,  which  is  characteristic 


96     INJURIES  AND  DISEASES  OF   HEAD  AND  NECK 

of  hydrops;  and  tumors  of  the  maxillary  bones  likewise 
grow  only  in  the  direction  in  which  they  encounter  the  least 
resistance.    They  do  not  cause  the  uniform  bulging   of  the 

Fig.  31 


Dental  cyst  of  the  lower  jaw  in  a  boy  aged  fourteen  years,  causing  uniform  distention 
of  the  walls  of  the  antrum.    (Von  Bergmann.) 

antral  walls  and  do  not  give  the  feeling  of  fluctuation. 
When  they  perforate  externally  or  into  the  nose,  mouth,  or 
orbit,  their  character  is  easily  determined. 

Fig.  32 


Pneumatocele  of  frontal  sinuses.    Note  the  distention  of  the  anterior  walls  of  the 
frontal  sinuses. 

It  is  well  in  the  case  of  the  antrum  of  Highmore  to  attempt 
to  ascertain  the  cause  of  the  distention.  Thus  one  or  more 
unerupted  teeth  suggest  the  presence  of  a  dentigerous  cyst; 
a  carious  tooth  with  an  old  history  of  subperiosteal  abscess 
suggests  a  subperiosteal  abscess  cyst,  which  strongly  simu- 


INJURIES  AND  NEOPLASMS  OF   THE  FACE 


97 


lates  a  chronic  hydrops  of  the  cavity;  and  in  the  absence  of 
either  of  these,  a  mucous  polypus  degeneration  is  probably 
present. 

Empyema. — An  acute  or  chronic  empyema  of  these 
cavities  usually  follows  an  infection  from  the  nose;  the  local 
evidences  of  distention  resemble  those  just  described,  but 
there  is  fever  and  more  pain  with  the  acute  purulent  infection 
of  the  sinuses.  The  history  of  a  preceding  nasal  infection 
suggests  the  character  of  the  malady,  and  a  periodic  evacua- 
tion of  considerable  quantities  of  purulent  fluid  through  the 
nose  is  further  evidence  of  it.     Retention  of  the  pus  within 

Fig.  33 


Fibroma  epulis  of  the  upper  gum  from  a  woman  aged  twenty-eight  years.  Note 
the  smooth  contour,  in  comparison  with  the  irregular  surface  of  tumor  in  Fig.  34. 
(Von  Bergmann.) 

the  cavities  is  evidenced  by  chills,  fever,  and  sweating;  by 
an  increased  tenderness,  and  by  a  feeling  of  distention  of  the 
walls  of  the  cavity. 

A  fistula  discharging  pus  and  leading  into  the  sinus  cavity 
points  to  an  empyema,  but  aifords  no  information  as  to  the 
cause  thereof. 

Periosteal  Neoplasms. — Periosteal  neoplasms  of  the  max- 
illary bones,  of  which  those  that  spring  from  the  alveolar  pro- 
cesses, i.  e.,  the  epules,  are  the  most  common,  are  readily 
detected.  They  lie  upon  the  bone.  The  benign  tumors  and 
the  giant-celled  sarcomata  form  hard,  sessile,  slowly  growing 
tumors;    the   malignant    neoplasms   grow  rapidly,  undergo 

7 


98     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

ulceration  early,  and  cause  rapid  bone  destruction.  The 
nature  of  the  periosteal  growth  is  sometimes  very  difficult  to 
determine.  Malignancy  is  often  to  be  decided  only  by  the 
microscope  and  from  the  rapidity  of  growth. 


Sarcomatous  epulis  in  a  woman  aged  fifty-six  years.    (Von  Bergmann.) 

Fig.  35 


Medullary  sarcoma  of  the  left  superior  maxillary  bone  growing  downward  toward 
the  mouth,  and  outward.  Note  the  displacement  of  the  angle  of  the  mouth,  the 
absence  of  exophthalmos.  Compare  with  Fig.  30,  of  chronic  hydrops  of  antrum  of 
Highmore,  in  which  there  is  uniform  bulging  of  all  the  walls  of  the  antrum. 


INJURIES  AND   NEOPLASMS  OF   THE  FACE 


99 


A  fibroma  is  not  so  hard  as  an  osteoma,  but  periosteal 
and  myeloid  sarcomata  are  at  times  of  bony  hardness  and 
thereby  resemble  the  osteoma;  with  the  former,  however, 
there  is  marked  bone  destruction. 

The  periosteal  swelling  which  is  due  to  an  acute  inflam- 
mation is  distinguished  from  that  due  to  neoplasm  by  its 
sudden  appearance  and  by  the  presence  of  acute  pain,  fever, 
and  increased  leukocytosis. 

Fig.  36 


Periosteal  sanjoina.     (Von  Bergmann . ) 


Medullary  Tumors. — Medullary  tumors  can  only  be  de- 
tected when  they  become  large  enough  to  fill  the  cavity  of  the 
bone  and  expand  its  cortical  layer.  The  latter  forms  a  shell 
around  the  growing  tumor,  and  as  it  becomes  thinned  out  by 
the  increasing  size  of  the  neoplasm  it  crackles  on  palpation, 
and  thus  affords  a  valuable  clinical  sign,  viz.,  the  "egg-shell 


100     INJURIES  AND   DISEASES  OF  HEAD  AND  NECK 

crackle."  Benign  medullary  tumors  grow  slowly  and  gradu- 
ally cause  absorption  of  the  cortical  crackling  layer  surround- 
ing them,  but  the  latter  is  replaced  by  a  new  one  formed 
by  the  periosteum  which  is  irritated  by  the  growing  tumor. 
Benign  tumors  are,  as  a  rule,  therefore  surrounded  in  all 
stages  by  a  crackling  shell. 

Malignant  medullary  tumors  grow  rapidly,  and  very  early 
perforate  and  destroy  the  cortical  shell;  a  new  periosteal 
shell  is  not  formed,  however,  for  the  rapidly  growing  neo- 
plasm invades  and  destroys  this  membrane. 

Fig.  37 


Ulcerating  medullary  sarcoma  of  inferior  maxilla.    Note  fungous  character 
of  the  nicer. 


An  intact  shell  over  a  slowly  growing  neoplasm  is  evidence 
of  its  benign  character,  while  a  perforated  or  partially 
destroyed  shell  over  a  rapidly  growing  tumor  is  evidence  of 
its  malignancy. 

Medullary  tumors  grow  in  the  direction  of  least  resistance : 
upward  toward  the  antrum,  outward  at  the  canine  fossa, 
inward  toward  the  nose,  etc.  The  cavities  of  the  bones  are 
filled  by  the  neoplasm,  and  their  walls  are  bulged  outward, 
thus  displacing  the  eyeball,  obstructing  the  nose,  interfering 


INJURIES  AND   NEOPLASMS   OF   THE  FACE       101 

with  the  movements  of  the  tongue  and  projecting  into  the 
Hoor  of  the  mouth.  The  mahgnant  tumors,  especially  the 
carcinomata,  ulcerate  rapidly. 

The  swelling  of  the  bone,  which  is  due  to  a  chronic  osteo- 
myelitis, comprises  the  entire  outline  of  the  bone;  it  is  thereby 

Fig.  38 


Retromaxillary  fibroma,  pushing  the  superior  maxilla  forward.    (Von  Bergmann.) 


distinguished  from  that  due  to  a  neoplasm,  which  is  confined 
chiefly  to  one  side  or  border  of  the  bone.  The  irregularity 
of  the  swelling,  the  presence  of  sinuses  leading  down  to 
exposed  bone,  and  the  discharge  of  a  profuse  amount  of  pus 
are  further  data  in  favor  of  the  inflammatory  character  of 
the  swelling. 


102     INJURIES  AND  DISEASES  OF   HEAD  AND  NECK 

The  differentiation  of  medullary  neoplasms  of  the  superior 
maxilla  from  hydrops  and  chronic  empyema  of  its  cavity 
has  already  been  discussed  on  page  95. 


Fig.  39 


Myelogenous  sarcoma.    (Von  Bergmann.; 


CHAPTER  VIIL 

INFLAMMATION    AND    NEOPLASMS    OF    THE    MOUTH, 

TONGUE,  TONSILS,  PHARYNX,  AND  SALIVARY 

GLANDS. 

INFLAMMATION    AND    ULCERATION    OF    THE    MOUTH. 

IjITTLE  difficulty  is  experienced,  as  a  rule,  in  determining 
the  nature  of  inflammatory  and  ulcerative  diseases  of  the 
mucous  membrane  of  the  mouth.     The  gross  appearance 


Epithelial  carcinoma  of  the  cheek.    A  difluse,  hard,  infiltrating  tumor,  ulcerating  at 
its  posterior  part.    The  ulcer  has  everted  edges. 


104     INJURIES   AND   DISEASES  OF  HEAD   AND  NECK 

and  site  of  t.lie  lesion,  taken  in  conjunction  with  the  ante- 
cedent personal  history,  will  usually  enable  the  observer  to 
make  a  correct  diagnosis.  Thns,  the  extremely  sensitive, 
grayish  or  yellowish  spots  from  pin's  head  to  lentil-seed  size, 
occurring  on  the  gums  and  buccal  mucous  membrane,  espe- 
cially in  teething  children,  speak  for  aphthce.  The  punctate 
and  linear  spots  of  a  dirty  whitish  color  which  occur  on  the 
dried  and  sensitive  mucous  membrane  of  the  gums,  cheeks. 

Fig.  41 


Noma.    Early  stage,  showing  swollen,  tense  cheek,  with  gangrenous  patch  in  one 
part.    (Lexer.) 

and  tongue  of  weakened  and  marasmic  individuals  are  char- 
acteristic of  soor. 


The  swelling  and  slight  bleeding  from  the  gums  of 
those  who  are  taking  mercury  without  observing  the  usual 
precautions  are  indicative  of  mercurial  stomatitis  and  are  a 
warning  to  the  patient  that,  unless  more  care  of  the  mouth 


INFLAiMMATIOX  AXD  XEOPLASMS  OF  THE  MOUril      105 

is  observed,  the  teeth  will  become  loose  aiul  ulceration  and 
necrosis  of  the  alveolar  process  o^'  tlie  maxilla  will  occur. 

Swelling,  congestion,  softening,  and  bleeding  from  the 
gums  in  individuals  who  have  in  the  bones  and  soft  parts 
other  evidences  of  scurvy  or  who  give  a  history  of  rickets 
and  hsematuria,  are  an  evidence  of  this  affection. 

The  indurated  sore,  which  within  a  few  weeks  attains  a 
considerable  size  and  is  accompanied  by  submaxillary  gland- 

FlG.  42 


Noma.    Later  stage,  showing  extensive  gangrene  and  sloughing  of  the  cheek. 

(Lexer.) 


ular  swelling,  followed  by  the  other  evidences  of  syphilis,  is  the 
initial  lesion  of  this  disease.  Superficial  erosions  and  fissures, 
or  flat,  red,  circumscribed  papules  which  sometimes  ulcerate, 
and  broad  condylomata,  are  evidences  of  the  secondary  period 
of  syphilis;  and  circumscribed  soft,  elastic  nodules  of  varying 
size,  sometimes  ulcerating  and  tending  to  perforate  the  part 
which  is  affected,  are  indicative  of  the  final  stage  of  this 
disease. 


106     INJURIES   AND   DISEASES   OF   HEAD   AND   NECK 

A  gangrenous  patch  on  the  mucous  membrane  of  a  tense, 
shiny,  and  swollen  cheek  in  marasmic  and  much- weakened 
individuals,  especially  children,  the  gangrene  having  •  a 
tendency  to  spread  through  the  entire  thickness  of  the  cheek 
and  even  to  the  bones  of  the  face,  together  with  severe 
constitutional  symptoms  of  sepsis,  is  pathognomonic  of  noma.' 

Tuberculosis,  actinomycosis,  and  cancerous  disease  of  this 
region  have  the  same  characteristics  as  similar  affections  of 
the  tongue  and  pharynx. 

DISEASES  OF  THE  TONGUE. 

Acute  inflammatory  conditions  of  this  organ  manifest 
their  presence  by  an  acute  onset  with    high   temperatures, 

Fig.  43 


Chronic  abscess  of  the  tongue  ;  a  painful,  fluctuating  swelling, 

together  with  a  rapid,  painful  swelling  of  the  tongue  which 
either  resolves  in  a  few  days  or  goes  on  to  form  an  abscess. 
Simple  as  is  the  diagnosis  in  these  cases,  so  difficult  is  it  at 
times  in  the  ulcerative  lesions  that  result  from  chronic 
inflammations  such  as  syphilis,  tuberculosis,  and  actinomy- 
cosis.    These  bear  so  much  resemblance  to  one  another  and 


INFLAMMATION  AND  NEOPLASMS  OF  THE  MOUTH      107 

to  the  ulcerations  which  residt  from  mahgnant  disease  that 
their  differentiation  is  often  attended  with  considerable 
difficulty.  A  preceding  history  of  syphilis,  or  the  presence 
of  other  syphilitic  lesions  in  the  bones  or  the  skin  or  mucous 
membranes,  or  the  evidences  of  tuberculosis  in  the  lungs, 
bones,  joints,  etc.,  will  afford  valuable  data  for  establishing 
a  diagnosis;  but  in  all  doubtful  cases  we  should  remember, 
first,  to  try  the  effect  of  antisyphilitic  treatment,  and,  secondly, 
to  submit  an  excised  specimen  of  the  lesion  to  expert  patho- 
logical examination. 

Tuberculosis. — Tuberculosis  of  the  tongue  may  resemble 
both  carcinoma  and  syphilis.  It  is  very  rarely  a  primary 
lesion;  most  frequently  it  is  secondary  to  pulmonary  tuber- 
culosis, the  bacilli-laden  sputum  and  the  injury  of  the 
tongue  from  sharp  teeth  being  the  causes  of  infection. 
Its  initial  manifestations  are  hard,  painless,  slowly  growing- 
nodules  that  strongly  resemble  carcinomatous  nodules. 
When  these  break  down  they  leave  an  indolent,  fungous, 
indurated  ulcer,  which  is  distinguished  from  carcinoma  by 
its  worm-eaten,  cheesy  base,  often  surrounded  by  miliary 
tubercles,  and  by  the  pale,  flabby  granulations  with  which 
it  is  covered;  the  presence  of  tuberculous  lesions  elsewhere 
in  the  body  assist  in  making  the  diagnosis.  From  ulcerating 
gummata  the  softened,  broken-dowm,  and  ulcerated  tuber- 
culous nodes  are  distinguished  by  their  initial  hardness,  their 
cheesy  base  and  indurated  edges ;  the  presence  of  tuberculous 
lesions  in  the  lungs  and  the  absence  of  a  history  of  syphilis 
or  other  evidences  of  this  disease  are  further  aids  in  their 
differentiation. 

Syphilis — A  rapid  development  of  an  indurated  sore  on 
the  tongue,  with  an  early,  painless,  submaxillary  glandular 
involvement,  together  with  a  rapid  improvement  from  the 
administration  of  mercury,  speak  strongly  enough  for  the 
initial  lesion  of  syphilis;  while  sharp  margins,  rounded  form, 
multiplicity,  and  lack  of  all  inflammatory  reaction  distinguish 
the  superficial  ulcerations  which  attend  the  secondary  period 
of  this  disease.  The  ulcers  which  arise  from  the  softening 
and  breaking  down  of  gummata  are  distinguished  from 
tuberculous  lesions  by  their  initial  appearance  as  soft,  elastic 
nodules  usually  multiple  in  number,  and  by  the  characte^^ 


108      INJUBIES  AND   DISEASES   OF  HEAD   AND    NECK 

istics  of  the  ulcer,  viz.,  soft,  sharp  borders  with  lardaceous 
base  that  clear  up  rapidly  on  taking  iodides  and  mercury. 
To  these  data  a  previous  history  of  syphilis  and  the  presence 
of  syphilitic  lesions  in  the  other  organs  lend  confirmatory 
evidence.  The  sclerosing  form  of  syphilitic  glossitis  is  not 
very  common.     It  is  well  pictured  in  Fig.  44. 

Actinomycosis. — ^The  first  manifestations  of  this  malady 
are  pea  to  hazelnut-sized,  sharply  circumscribed,  hard,  usually 
painless  nodules  at  the  sides  and  tip  of  the  tongue,  covered 
by  congested  mucous  membrane.  These  grow  slowly  larger, 
then  softer,  and   later  on  fluctuant,  and   eventually  break 

Fig.  44 


Sclerosing  syphilitic  glossitis.  The  tongue  is  hard  ;  the  mucous  membrane  is  red  in 
places  and  white  in.  others  ;  the  organ  is  atrophied,  and  its  surface  is  covered  by  a  series 
of  projections  and  fissures.    (Reclus.) 

down  and  leave  an  ulcer.  The  diagnosis  of  actinomycosis  is 
confirmed  by  a  discharge  from  the  ulcerating  area  of  minute 
yellowish  granules  that  on  microscopic  examination  are  found 
to  contain  the  ray  fungus.  The  nodules  are  differentiated 
from  those  due  to  tuberculosis  or  syphilis  by  the  course  of 
their  development  and  by  the  absence  of  other  tuberculous 
and  syphilitic  lesions ;  and  the  ulcers  which  result  from  these 
nodules  are  distinguished  from  those  due  to  carcinoma  by 
their  multiplicity,  their  sharp  margins  and  their  softer 
consistency. 


INFLAMMATION  AND   NEOPLASMS  OF  THE  MOUTH      109 

Carcinoma. — This  affection  usually  occurs  in  middle-aged 
or  elderly  subjects;  it  commences  as  an  indurated  crack  or 
fissure  or  nodule  on  the  side  or  dorsum  of  the  tongue  which 
persistently  refuses  to  heal;  it  advances  rather  rapidly,  and 
is  later  on  followed  by  enlargement  and  induration  of  the 
submaxillary  glands,  with  ulceration  at  the  site  of  the  lesion 
on  the  tongue,  the  ulcer  having  hard,  everted  edges  and  an 
unhealthy,  easily  bleeding  base.  The  early  nodules  are  to 
be  distinguished   from  those   due   to  tuberculosis,  syphilis. 


Fig.  45 


Fig.  46 


Fig.  45.— Gumma  and  syphilitic  fissures  of  tongue.  Note  soft,  elastic,  circumscribed 
tumor  and  the  other  evidences  of  syphilis  in  the  fissures  of  the  tongue.    (Reclus.) 

Fig.  46. — Syphilitic  tongue  after  resorption  of  the  gumma  by  iodides.  Note  the 
fissures  and  the  retraction  of  the  tongue  at  the  site  of  the  gumma.    (Reclus.) 


and  actinomycosis  by  their  hardness  and  their  lack  of  sharply 
defined  margins,  by  the  course  of  their  development,  and  by 
the  absence  of  other  tuberculous  or  syphilitic  lesions.  Carcino- 
matous ulcers  differ  from  tuberculous  and  syphilitic  ulcers 
in  their  indurated,  everted  edges,  and  their  unhealthy,  easily 
bleeding,  rather  extensive  base.  A  marked  interference  with 
the  movements  of  the  tongue,  a  considerable  enlargement  of 
the  submaxillary  glands  and  early  cachexia,  are  further  evi- 
dences of  malignant  disease. 


no     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

To  recapitulate : 

Nodules. — Nodules  in  the  tongue  may  be: 

Tuberculous.  Occurring  in  young  subjects,  with  other  evi- 
dences of  tuberculosis,  hard  at  onset,  painless,  of  slow  growth. 

Syphilitic  Gummata.  These  occur  at  any  age,  with  other 
syphilitic  lesions  in  the  bones,  skin,  etc.;  they  are  usually 
multiple  and  have  a  soft  and  elastic  consistency. 

Fig.  47 


Carcinoma  of  the  tongue.    Note  its  site,  its  diffuse  character,  its  irregular,  ulcerated 
surface,  and  the  everted  edges  of  the  ulcer. 

Actinomycotic .  These  occur  in  young  adult  life ;  the  nodules 
are  multiple,  sharply  circumscribed,  hard  at  the  beginning, 
usually  painless,  located  at  tip  or  sides  of  tongue,  and  develop 
in  two  to  eight  weeks. 

Carcinomatous.  These  occur  in  middle  or  advanced  age; 
they  are  very  hard,  with  diffuse  margins,  somewhat  painful, 
and  are  attended  with  marked  glandular  involvement. 

Chronic  Abscess.     This  is  very  painful  and  fluctuates. 


INFLAMMATION  AND  NEOPLASMS  OF  THE  MOUTH     HI 

Ulcers. — Ulcers  of  the  tongue  may  be: 
Tuberculous.      The  edges  are  soft,  the  base  worm-eaten, 
cheesy,  covered  by  pale,  flabby  granulations,  and  surrounded. 

Fig.  48 


Papillomata  of  tongue.    Note  their  multiplicity,  their  sharply  circumscribed  charac- 
ter, and  the  absence  of  ulceration. 

Fig.  49 


Tuberculosis  of  tongue,  secondary  to  laryngeal  tuberculosis.    Note  worm-eaten  char- 
acter of  ulcer  and  the  smaller  tubercles  and  ulcers  which  surround  it. 

as  a  rule,  by  miliary  tubercles  or  smaller  ulcerations.  There 
are  usually  evidences  of  tuberculosis  in  the  lungs,  bones,  or 
joints. 


112     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Syphilitic,  The  edges  are  soft  and  sharp,  the  base  waxy,  and 
there  are,  as  a  rule,  other  evidences  of  syphiHs  in  the  bones, 
skin,  etc.  On  using  iodides  and  mercury  the  ulcer  rapidly 
heals. 

Actinomycotic.  Are  distinguished  by  the  discharge  of  minute 
yellowish  granules  containing  the  ray  fungus. 

Carcinomatous.  The  edges  are  everted  and  indurated,  the 
base  is  extensive  and  covered  by  unhealthy,  easily  bleeding 
granulations,  and  there  is  marked  impairment  of  the  move- 
ments of  the  tongue.  The  course  is  rapid;  there  is  marked 
glandular  involvement,  early  cachexia,  and  metastases. 

In  every  case  it  is  essential  to  obtain  a  careful  family  and 
pre^dous  history,  and  to  elicit  as  accurately  as  possible  an 
account  of  the  earliest  evidences  of  the  disease,  its  duration, 
and  its  course.  The  physical  examination  should  include 
the  skin,  bones,  and  internal  organs ;  and,  finally,  in  doubtful 
cases  a  section  should  be  given  to  the  pathologist  for  exami- 
nation. 

DISEASES  OF  TONSIL  AND  PHARYNX. 

What  has  been  said  of  tuberculosis,  syphilis,  and  actino- 
mycosis of  the  tongue  applies  equally  well  of  these  affections 
when  they  are  located  in  the  tonsils  and  pharynx.  Enlarge- 
ment of  the  tonsils  is  due  to  abscess,  chronic  hyperplasia, 
lues,  or  malignant  disease.  An  acute  onset  of  constitutional 
symptoms,  together  with  pain,  swelling,  and  fluctuation  of 
the  organ,  characterize  the  acute  abscesses;  while  a  soft, 
boggy,  fluctuating  enlargement  coming  on  after  one  or  more 
previous  attacks  of  acute  inflammation,  and  without  consti- 
tutional disturbances,  speaks  for  a  chronic  abscess. 

Gradually  developing  nasal  voice  and  mouth  breathing, 
with  repeated  attacks  of  acute  inflammation  of  the  throat, 
cough,  or  ear  discharge,  especially  in  young  children,  suggest 
chi'onic  hyperplasia  of  the  tonsils  and  adenoid  vegetations 
in  the  nasopharynx.  The  tonsils  in  these  cases  are  enlarged 
and  soft,  sometimes  their  crypts  are  distended  into  little 
cysts,  and  again  the  orifices  of  the  crypts  are  plugged  with 
a  pearly  white  material.  The  cysts  may  attain  the  size  of 
a  large  walnut;  their  rather  rapid  development,  tense  and 


INFLAMMATION  AND  NEOPLASMS  OF   THE  MOUTH     113 

fluctuating  character,  and  mobility  upon  the  deeper  struc- 
tures, readily  proclaim  their  benign  cystic  nature. 

Fig.  50 


Ulcerating'gumma  of  soft  palate ;  smooth,  soft,  elastic  tumor  in  a  syphilitic  subject. 

Fig.  51 


Tuberculosis  of  the  right  tonsil.    Note  worm-eaten  character  of  edges  of  ulcer  and 
the  surrounding  tubercles  and  smaller  ulcerations. 

The  swelling  of  the  tonsil  due  to  sarcoma  is  hard,  increases 
rapidly  in  size,  soon  becomes  fixed  to  the  surrounding  tissues 


114     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Fig.  52 


Peritonsillar  abscess  on  the  left  side.    (Coakley.) 


Fig    53 


Adenoid  facies.    Note  the  half-open  mouth,  the  atrophic  and  immobile  nostrils,  the 
obliteration  of  the  naso-labial  folds,  and  the  lack  of  facial  expression. 


INFLAMMATION  AND  NEOPLASMS  OF   THE  MOUTH     U5 

and  ulcerates,  leaving  an  easily  bleeding,  fungous,  indurated 
mass.  It  occasions  considerable  pain,  which  radiates  to  the 
ears,  and  when  the  tumor  attains  sufficient  size  it  interferes 
wath  l)reathing  and  swallowing.  In  its  early  stages  it  may 
be  mistaken  for  chronic  hyperplasia,  but  this  latter  is,  as  a 
rule,  bilateral  and  with  it  the  tonsil  is  much  softer  in  con- 
sistency. A  gumma,  especially  when  ulcerated,  may  be 
mistaken  for  sarcoma;  but  its  appearance  and  feel  before 
ulceration,  viz.,  that  of  an  elastic,  circumscribed,  soft  nodule 
which  is  not  fixed,  and  the  entire  dissimilarity  of  the  ulcers, 
together  with  a  previous  history  of  syphilis  and  the  presence 
of  other  syphilitic  lesions,  readily  enable  us  to  differentiate 
the  two  conditions. 

We  must  be  careful  not  to  confound  a  sarcomatous  degen- 
eration of  the  lymphatic  gland  which  lies  on  the  pharyngeal 
wall  directly  behind  the  tonsils  with  sarcoma  of  the  tonsil 
itself.  This  is  a  likely  error,  because  the  enlargement  of  the 
lymphatic  gland  gives  rise  to  a  tumor  in  the  oropharynx  on 
the  top  of  which  rides  the  tonsil.  The  fact  that  the  tonsil 
is  soft  and  movable  and  not  enlarged  should  enable  us  to 
make  the  differential  diagnosis. 

Cancerous  disease  of  the  tonsil  and  pharynx  is  to  be  recog- 
nized by  the  same  characteristics  as  pertain  to  similar  affec- 
tions of  the  mouth  and  tongue.  Pain  in  the  head  or  ear, 
disturbances  in  hearing,  and  a  foul  discharge  of  pus  and 
blood  from  the  nose  are  often  the  first  indications  afforded 
by  a  carcinoma  in  the  vault  of  the  pharynx,  just  as  induration 
and  enlargement  of  the  submaxillary  lymphatic  glands  are 
often  the  first  evidences  of  a  carcinoma  in  the  mesopharynx  or 
hypopharynx.  These  facts  should  teach  us  to  carefully  inspect 
and  palpate  these  parts  when  an  elderly  subject  complains  of 
pain  in  the  ear,  or  foul  nasal  discharge,  or  notices  a  swelling 
in  the  submaxillary  region.  In  the  later  stages  of  cancerous 
disease  of  these  parts  the  characteristic  ulcer  and  the  marked 
disturbances  in  breathing  and  swallowing  leave  little  doubt  as 
to  the  nature  of  the  malady. 

In  children  and  in  young  adults  we  sometimes  find,  as  a 
cause  for  nasal  voice,  mucopurulent  nasal  discharge,  and 
mouth  breathing,  a  tumor  in  the  vault  of  the  nasopharynx 
which  projects  from  the  base  of  the  skull.     The  tumor  is 


116     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

hard  and  nodular;  as  it  grows  it  fills  the  nasopharynx,  pushes 
the  superior  maxillary  bones  forward,  the  roof  of  the  mouth 
downward,  causes  the  eyeballs  to  protrude  from  their  sockets, 
and  completely  obstructs  the  posterior  nares.    It  thus  inter- 

FiG.  54 


Retropharyngeal  tumor,  causing  interference  with  breathing  and  swallowing.    The 
diagnosis  is  readily  made  by  inspection  and  palpation  of  the  oropharynx.  (Albert.) 

feres   with   breathing   and   swallowing.     Such   tumors   are 
usually  fibrosarcomata. 

DISEASES  OF  THE  SALIVARY  GLANDS.     • 

Tumors  of  the  Floor  of  the  Mouth.— Of  swelKngs  which 
bulge  into  or  occupy  the  floor  of  the  mouth,  we  must  dis- 
tinguish  between   those  which   develop  acutely  and  those 


INFLAMMATION  AND  NEOPLASMS  OF  THE  MOUTH     117 

which  form  slowly;  the  former  are  due  to  acute  inflammation, 
the  latter  to  chronic  inflammation,  syphilis,  tuberculosis, 
neoplasms,  or  cysts  of  the  submaxillary  or  sublingual  salivary 
glands,  the  submaxillary  lymphatic  glands,  the  Blandin- 
Nunin  glands,  to  cell  inclusions  that  have  taken  place  during 
fetal  development,  or  to  affections  of  a  persistent  thyroglossal 
duct. 

Acute  Inflammatory  Swellings  of  Salivary  Glands. — An  acute 
onset  of  pain,  tenderness,  and  moderate  swelling  of  the  sub- 
maxillary or  sublingual  glands,  with  slight  constitutional  dis- 
turbances, characterize  simple  inflammation  of  these  organs; 


Fig.  55 


Fig.  56 


Fig.  55. — Vegetant  myosarcoma  of  nasopharynx. 
Fig.  56.— Fibrosarcoma  of  the  nasopharynx.    (Albert.) 

whereas  exquisite  pain  and  tenderness  with -severe  constitu- 
tional symptoms  and  extensive  brawny  induration  of  the  floor 
of  the  mouth  and  submaxillary  region  of  the  neck  indicate 
a  phlegmonous  inflammation  of  the  submaxillary  gland — i.  e., 
an  angina  Ludovici  or  cynanche.  The  more  gradually  appear- 
ing swellings  most  often  seen  are  ranulse,  dermoid  and  thyro- 
glossal cysts,  chronic  inflammatory  tumors  of  the  submaxillary 
and  sublingual  salivary  glands,  neoplasms  of  these  latter 
organs,  and  inflammatory  or  neoplastic  tumors  of  the  sub- 
maxillary lymphatic  glands. 


118      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Ranula. — ^A  rounded  or  egg-shaped  cystic  tumor  which  is 
neither  tender  nor  painful,  situated  under  the  tongue,  is 
characteristic  of  ranula;  such  a  tumor  is  due  to  a  cystic 
dilatation  of  the  chief  ducts  of  the  Blandin-Nunin  glands, 
which  are  situated  at  the  tip  of  the  tongue. 

Salivary  Calculus. — A  smooth,  somewhat  tender,  fluctuating 
swelling  of  the  submaxillary  or  sublingual  salivary  glands 
appearing  somewhat  rapidly,  but  without  constitutional 
symptoms,  should  always  suggest  the  possibility  of  its  being 

Fig.  57 


Ranula.    (Von  Bergmann.) 

due  to  occlusion  of  the  ducts  of  these  glands  by  a  calculus. 
If  a  hard  nodule  is  felt  in  the  duct,  or  if  a  bristle  passed  into 
the  duct  meets  with  a  hard,  gritty  obstruction,  the  diagnosis 
of  a  calculus  in  the  duct  may  safely  be  made;  only  rarely 
does  the  calculus  protrude  from  the  duct  so  as  to  be  visible. 
It  should  also  be  remembered  that  an  acute  inflammation  may 
develop  in  such  an  occluded  gland  at  any  time ;  if  a  calculus 
protrudes  from  the  orifice  of  the  duct,  or  if  the  patient  gives  a 
previous  history  of  pain  or  of  irritation  in  the  floor  of  the 
mouth  with  or  without  a  swelling  of  the  gland,  the  cause  of 
the  inflammation  will  become  clear. 


INFLAMMATION  AND  NEOPLASMS  OF  THE  MOUTH     119 

Chronic  Inflammatory  Tumors  of  the  Salivary  Glands. — ^The 
swellings  due  to  chronic  inflammation,  syphilis,  tuberculosis, 
and  to  the  early  stages  of  the  neoplasms  of  the  submaxillary 
and  sublingual  salivary  glands  are  very  similar  in  their 
characteristics  and  can  in  most  instances  only  be  told 
apart  by  histological  examination  of  an  excised  specimen. 
A  previous  history  of  syphilis,  or  the  presence  of  other  syphil- 
itic lesions,  or  an  entire  disappearance  of  the  swelling  from 

Fig.  58 


^'■a 


Mixed  tumor  of  the  submaxillary  gland.    (After  a  case  in  v.  Bruns'  clinic.) 

antisyphilitic  treatment,  are  strong  evidences  of  its  syphilitic 
character.  The  safest  plan  of  procedure  in  the  differentiation 
of  these  swellings  is  the  following:  First  administer  anti- 
specific  treatment  for  ten  to  fourteen  days,  and  if  no  marked 
improvement  follows  therefrom,  immediately  excise  a  speci- 
men and  submit  it  to  histological  examination. 

Not  only  are  these  various  swellings  of  the  salivary  glands 
difficult  to  differentiate  from  one  another,  but  they  are 
equally  hard  to  distinguish  from  chronic  hyperplasia  or  other 


120      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

affections  of  the  submaxillary  lymph  glands.  It  happens 
now  and  then  that  an  isolated  lymph  gland  in  this  region 
becomes  enlarged  and  in  every  way  simulates  a  swelling  of 
the  salivary  glands.  As  the  indication  for  treatment  is  the 
same  in  either  case,  viz.,  to  excise  a  specimen  for  exami- 
nation, if  the  swelling  is  increasing  and  does  not  disappear 
after  antispecific  treatment,  the  necessity  for  differential 
diagnosis  is  not  so  pressing. 

Dermoid  cysts  and  thyroglossal  cysts  are  readily  distin- 
guished from  swellings  of  the  submaxillary  glands  by  their 
median  position  and  their  close  connection  with  the  hyoid 
bone.  Branchiogenetic  cysts  have  a  lateral  position  and  so 
may  be  erroneously  considered  as  tumors  of  the  salivary 
glands,  but  they  are  fluctuating  and  have  a  close  connection 
with  the  hyoid  bone  or  inferior  maxilla. 

Tumors  of  Parotid. — In  connection  with  the  swelHngs  of 
the  submaxillary  and  sublingual  salivary  glands,  those  of  the 
Parotid  are  of  interest.  Pain  behind  the  jaw  and  below  the 
ear,  ushered  in  by  a  chill  or  sudden  fever  and  accompanied 
by  a  painful  swelling  in  this  region  which  raises  up  the 
lobule  of  the  ear  and  fills  up  the  hollow  in  front  of  the 
sternocleidomastoid  muscle,  is  due  most  frequently  to  an 
acute  parotitis.  The  existence  of  an  epidemic  of  parotitis 
and  a  slight  severity  of  the  constitutional  symptoms  speak 
for  epidemic  parotitis  or  mumps,  whereas  a  greater  severity 
of  the  constitutional  symptoms  in  a  patient  who  is  suffering 
from  some  other  acute  infectious  disease,  such  as  pneumonia, 
are  in  favor  of  the  metastatic  or  suppurative  character  of  the 
inflammation.  The  possibility  of  such  an  inflammation  fol- 
lowing operations  should  not  be  forgotten. 

Circumscribed  or  diffuse  enlargements  of  the  parotid  are 
sometimes  due  to  benign  neoplasms — e.  g.,  angioma,  fibroma, 
lipoma,  or  myxoma;  they  all  grow  slowly  and  are  encap- 
sulated and  movable.  It  is  to  be  noted  that  no  tumor  is  to 
be  considered  of  parotid  origin  unless  it  is  connected  with 
the  gland  and  lies  beneath  the  parotid  masseteric  fascia. 
Probably  the  most  interesting  tumors  of  the  salivary  glands 
are  those  of  mixed  character.  These  are  benign,  but  they 
may  undergo  malignant  degeneration.  They  are  usually 
sharply  circumscribed  and  defined  from  the  surrounding 


INFLAMMATION  AND  NEOPLASMS  OF  THE  MOUTH     121 

tissues;  they  are  rounded  or  of  elongated  oval  form,  have  a 
smooth  or  lobulated  surface,  or,  when  cartilaginous  nodules 
are  present,  a  nodular  surface.  Their  consistency  varies 
from  pseudofluctuating  to  hard,  depending  upon  the  char- 
acter of  the  constituent  parts;  they  grow  slowly,  are  covered 
by  normal  skin,  and  are  perfectly  movable.  They  may 
attain  considerable  size;  the  presence  of  hard,  nodular  masses 
in  a  tumor  of  these  organs  may  be  taken  as  a  sign  of  its  mixed 
character.     Such  tumors,  when  small,  may  be  mistaken  for 

Fig.  59 


Mixed  tumor  of  the  parotid.    (After  a  case  in  v.  Bruns'  clinic.) 

enlargements  of  the  submaxillary  or  parotid  lymphatic  glands, 
from  which  they  can  be  differentiated  only  by  continued 
observation  and  by  microscopic  examination. 

Malignant  tumors  of  the  parotid  gland  in  their  early  stages 
very  strongly  resemble  the  chronic  inflammatory,  syphilitic, 
and  tuberculous  enlargements  of  this  organ.  No  positive 
means  exist  to  accurately  differentiate  these  various  maladies, 
and  the  same  rule  applies  here  as  was  given  for  the  differ- 


122     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

entiation  of  the  swellings  of  the  submaxillary  salivary  gland, 
viz.,  first  try  antisyphilitic  treatment,  and  if  it  does  not  cause 
material  improvement  within  ten  to  fourteen  days,  cut  down 
upon  the  tumor,  excise  a  specimen,  and  examine  it  under  the 
microscope. 

The  late  stages  of  malignant  disease  of  these  glands  are 
readily  recognized,  but  at  this  time  our  diagnosis  avails  us  but 
little,  as  no  radical  cure  can  be  effected.    A  hard,  retracted 


Fig.  60 


Angiosarcoma  of  parotid.    A  diffuse  hard  t\Huor  situated  below  ttie  parotid  fascia 
and  raising  up  the  lobule  of  the  ear. 

tumor  with  possibly  a  brawny  induration  of  the  skin,  as  occurs 
with  cancer  en  cuirasse,  and  an  early  development  of  facial 
palsy  with  late  induration  of  the  submaxillary  lymph  glands 
are  in  favor  of  the  tumor  being  a  scirrhous  cancer;  whereas  a 
large  tumor  that  early  perforates  through  the  skin  and  forms 
a  large,  fungous,  ulcerating  mass,  and  that  is  attended  with 
late  facial  paralysis  and  early  lymphatic  enlargement,  speaks 
for  a  medullary  cancer. 


CHAPTER  IX. 
INFLAMMATORY  DISEASES  OF  THE  NECK. 

The  complexity  of  the  anatomical  structure  of  the  neck 
and  the  varied  character  of  the  diseases  which  originate 
in  them  make  it  very  difficult  at  times  to  determine  the 
exact  nature  and  starting  point  of  a  new  growth  or  inflam- 
matory process  in  this  region.  Considerable  aid  in  both 
these  particulars  is  afforded  by  a  complete  anamnesis  and  a 
thorough  physical  examination,  but  a  decision  will  often  be 
best  arrived  at  by  a  process  of  exclusion. 

ACUTE  SUPPURATIVE  INFLAMMATIONS. 

The  severity  of  the  constitutional  symptoms  that  attend 
the  acute  inflammatory  affections  of  the  neck  causes  these 
maladies  to  stand  out  in  strong  contrast  to  the  chronic 
inflammatory  and  neoplastic  diseases  of  these  parts. 

Frequently,  and  especially  in  the  case  of  phlegmonous 
inflammations  arising  in  structures  which  are  encapsulated 
in  or  covered  by  the  dense  fibrous  cervical  fascia,  these 
constitutional  symptoms  are  very  severe;  the  temperature 
rising  to  104°  or  105°,  the  pulse  to  120  or  over,  and  that  with 
great  prostration.  An  acute  onset  of  such  severe  constitutional 
symptoms,  together  with  the  rapid  formation  of  a  brawny, 
tender,  exquisitely  painful  swelling  in  the  neighborhood  of  the 
submaxillary  gland,  in  the  thyroid  gland,  in  the  deep  cervical 
glands  along  the  anterior  border  of  the  sternocleidomastoid 
muscle,  or  in  the  deep  cervical  cellular  tissue,  are  pathogno- 
monic of  a  deep  phlegmonous  inflammation.  The  most 
frequent  site  of  such  an  inflammation  is  in  the  submaxillary 
gland  or  its  immediate  surroundings,  where  it  goes  under 
the  name  of  Angina  Ludovici  or  Cynanche.  In  this  location 
it  interferes  markedly  with  opening  the  mouth,  mastication, 


124     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

and  swallowing.  The  breath  has  a  fetid  odor,  the  saliva 
dribbles  constantly,  and  at  any  time  the  swelling  may  extend 
to  the  glottis,  in  which  case  suffocation  results  unless  prompt 
relief  by  tracheotomy  is  afforded. 

Acute  infection  of  the  retropharyngeal  glands  from  the 
nasopharynx  during  scarlet  fever,  influenza,  diphtheria, 
typhoid  fever,  etc.,  or  perforation  of  the  retropharyngeal 
wall  by  neoplasms  or  foreign  bodies,  frequently  gives  rise  to 
acute  retropharyngeal  abscess.  The  pus  in  these  abscesses 
may  burrow  forward  toward  the  pharynx,  or  laterally  to  the 
inner  or  outer  side  of  the  sternocleidomastoid  muscle,  or 
downward  to  the  mediastinum  or  upward  to  the  submaxillary 

Fig.  61 


Retropharyngeal  abscess. 

region,  forming  at  these  sites  a  fluctuating,  tender,  painful 
mass.  When  an  abscess  forms  in  the  retropharyngeal  tissues, 
the  neck  is  held  rigid  and  dorsally  flexed,  and  swallowing 
and  respiration  are  impeded  in  proportion  to  the  extent  of 
compression  or  encroachment  of  the  swelling  upon  the  larynx 
and  oesophagus. 

A  sudden  onset  of  fever,  with  nasal  voice,  impaired  respi- 
ration and  difficulty  in  swallowing,  in  a  child  who  has  suffered 
with  nasopharyngeal  disease,  are  very  suggestive  of  a  retro- 
pharyngeal abscess,  and  they  should  always  prompt  us  to 
examine  the  retropharyngeal  wall  with  the  finger,  and  to 
search  for  a  fluctuating,  tender  swelling  in  the  neck,  behind 


INFLAMMATORY  DISEASES  OF   THE  NECK        125 

the  carotid  vessels  to  the  inner  or  outer  side  of  the  sterno- 
cleidomastoid muscles. 

The  impaired  respiration  and  difficulty  in  swallowing  may 
lead  to  the  supposition  of  laryngeal  or  oesophageal  stenosis, 
a  supposition  that  can  at  once  be  set  aside  by  visual  exami- 
nation and  palpation  of  the  oropharynx.  Laryngeal  stenosis 
in  children  is  furthermore  usually  diphtheritic  and  is  evi- 
denced by  patches  of  membrane  on  the  uvula,  tonsils,  or  in 

Fig.  62 


Carbuncle  of  neck.    (Lexer.) 


the  nasopharynx,  by  a  characteristic  metallic  barking  cough, 
by  respiratory  stridor  and  hoarseness. 

It  is  to  be  noted,  however,  that  retropharyngeal  abscess 
may  complicate  diphtheria  of  the  nasopharynx.  The  exact 
condition  of  affairs  is  at  once  recognized  when  the  bulging, 
fluctuating  swelling  behind  the  pharynx  and  overhanging  the 
superior  laryngeal  and  oesophageal  orifices  is  seen  and 
palpated. 


126      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Of  the  superficial  acute  suppurative  inflammations  it  is 
necessary  to  differentiate  the  carbuncles,  the  furuncles,  and 
the  anthrax  pustules. 

Carbuncles. — These  are  frequently  found  in  diabetics, 
hence  the  importance  of  always  examining  the  urine  of  such 
patients.  They  occur  most  frequently  on  the  back  of  the 
neck,  as  single,  livid,  red,  painful,  tender,  ill-defined  swellings, 
the  surface  of  which  is  studded  with  small  vesicles,  which 
become  pustular,  break  down  and  lead  down  to  a  soft, 
grayish  slough. 

Fig.  63 


Anthrax  carbuncle.    Note  the  area  of  infiltration  on  which  there  are  several  small 
vesicles  surrounding  the  central,  gangrenous,  crust-covered  patch.    (Lexer.) 

Furuncles. — Furuncles  or  boils  are  usually  multiple  and 
occur  as  small,  well-defined,  painful  and  tender,  red,  conical 
swellings,  on  the  summit  of  which  a  small  pustule  forms, 
which  breaks  open  and  leads  down  to  a  greenish  slough. 

Anthrax  Pustules. — Anthrax  pustules  start  as  darkvesicles 
which  rapidly  become  pustular,  then  burst  and  dry  into  a 
crust.  The  surrounding  skin  is  swollen  and  covered  by  a 
crop  of  fresh  vesicles.  After  forty-eight  hours  constitutional 
symptoms  appear:  fever,  delirium,  diarrhoea.  In  some 
instances  the  pustules  resemble  a  diffuse  carbuncle,  the  over- 
lying skin  being  of  erysipelatous  redness.  The  diagnosis  is 
always  to  be  confirmed  by  an  examination  of  the  vesicular 
contents  for  the  bacillus  anthracis. 


INFLAMMATORY  DISEASES  OF   THE  NECK        127 


CHRONIC  SUPPURATIVE  INFLAMMATIONS. 

The  chronic  suppurative  inflammations  which  originate  in 
the  glandular  structures  are  tuberculous,  pyogenic,  or 
syphilitic  in  character,  while  those  that  occupy  the  cellular 
tissue  are  due  to  actinomycosis,  or  to  tuberculous  or  syphilitic 
caries  of  the  cervical  vertebrae,  mastoid  process,  sternum,  etc. 
Caries  of  the  vertebrae  occasion  the  chronic  retropharyngeal 
abscess. 

Fig.  64 


Actinomycosis  of  cheek  originating  in  lower  jaw.    (Illich. 


Tuberculous  Glandular  Abscesses. — The  tuberculous 
glandular  abscesses  form  characteristic,  slowly  growing, 
circumscribed,  fluctuating,  painless  swellings.  As  a  rule,  the 
lymphatic  glands  of  an  entire  group  become  fused  together, 
and  break  down  into  one  or  more  abscesses.  The  presence  of 
scars  and  fistulse  from  previous  suppurations  and  the  existence 
of  tuberculous  foci  in  the  lungs,  bones,  etc.,  make  the  diag- 
nosis positive. 

Actinomycosis  of  Cellular  Tissue. — Actinomycosis  of  the 
cellular  tissue  manifests  itself  as  a  diffuse,  slowly  growing, 
painless  swelling  which  gradually  softens  in  the  centre  while 
its  periphery  is  hard  and  brawny.    The  skin  becomes  livid 


128      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

and  breaks  down,  and  from  the  sinus  is  discharged  a  slimy, 
purulent  material  containing  yellowish  granules  that  on 
microscopic  examination  show  the  ray  fungus.  Acute  phleg- 
monous actinomycosis  due  to  a  mixed  bacterial  infection  is 
a  rare  manner  in  which  the  disease  manifests  itself.  The 
actinomycotic  infection  can  usually  be  traced  to  the  socket 
of  a  carious  tooth  where  the  fungus  has  gained  entrance;  the 
disease  spreads  by  direct  continuity  through  the  cellular 
tissues;  it  is  never  carried  by  the  lymphatics  to  the  glands, 
which  latter  are  consequently  not  enlarged. 

Actinomycosis  is  distinguished  from  tuberculosis  by  the 
diffuse  induration  which  surrounds  small  foci  of  softening, 
and  by  the  absence  of  glandular  enlargement.  From  malig- 
nant disease  actinomycosis  is  to  be  differentiated  by  the  areas 
of  softening  in  the  indurated  mass,  by  the  extent  of  the 
induration,  and  by  the  absence  of  glandular  involvement. 

From  gumma  the  differentiation  is  to  be  made  by  the  lack  of 
a  previous  history  of  syphilis,  by  the  absence  of  other  tertiary 
lesions,  and  by  the  finding  of  the  ray  fungus  in  material 
aspirated  from  the  swelling.  The  administration  of  iodides 
will  not  avail  much  in  the  differentiation  of  the  two  diseases, 
for  this  acts  favorably  upon  both  conditions. 

In  the  ulcerative  stage  of  actinomycosis,  the  discharge  of 
the  characteristic  yellowish  granules,  which  show  on  micro- 
scopic examination  the  ray  fungus,  makes  the  diagnosis 
clear. 

Tuberculosis  or  Syphilis  of  the  Cellular  Tissue. — Tuber- 
culosis or  syphilis  of  the  cervical  vertebrae  may  occasion  a 
chronic  retropharyngeal  abscess  which  points  either  in  the 
retropharyngeal  wall,  causing  a  nasal  character  to  the  voice, 
impaired  respiration  and  dysphagia,  or  appears  in  the  lateral 
region  of  the  neck,  to  the  inner  or  outer  side  of  the  sterno- 
cleidomastoid muscle,  but  always  behind  the  carotid  vessels. 

The  usual  evidences  of  spondylitis — viz.,  rigidity  of  the 
neck,  deformity  of  the  cervical  spine,  and  local  pain  over  the 
diseased  vertebrae  on  pressure  and  motion — will  throw  light 
upon  the  character  and  origin  of  a  fluctuating  swelling  in  the 
retropharynx,  or  in  the  lateral  region  of  the  neck  to  the  inner 
or  outer  side  of  the  sternocleidomastoid  muscle  with  the 
carotid  vessels  lying  upon  it.     The  nasal  voice  and  impaired 


INFLAMMATORY  DISEASES  OF   THE  NECK        129 

respiration  and  dysphagia  may  first  attract  attention  to  the 
retropharyngeal  tumor.  The  previous  history  of  syphihs 
will  lead  us  to  suspect  this  as  a  cause  of  the  vertebral  caries, 
especially  if  the  patient  is  otherwise  healthy  and  has  no  other 
tuberculous  foci. 

Tuberculosis  or  syphilis  of  the  mastoid  process,  sternum, 
etc.,  may  give  rise  to  a  cold  abscess  in  the  cellular  planes, 
which  can  be  readily  recognized  and  traced  to  the  primary 
focus  of  disease. 


CHRONIC  FLUCTUATING  SWELLINGS. 

A  chronic  fluctuating  swelling  of  the  neck  unattended  by 
constitutional  symptoms,  and  with  no  especial  pain  or  tender- 
ness, may  be  a  cystic  neoplasm,  an  aneurysm,  or  a  chronic 
abscess. 

For  their  differentiation  it  is  important  to  remember  that 
chronic  abscesses  are  in  the  vast  majority  of  cases  tuberculous, 
actinomycotic,  or  syphilitic,  and  are  secondary  to  diseases  of 
the  glands,  cervical  vertebrae,  sternum,  mastoid  process,  or 
lower  jaw,  etc.  If  the  glands  do  not  show  the  characteristic 
fusing  into  masses;  if  there  are  no  irregular  scars  or  fistulse 
on  the  neck,  pointing  to  previous  suppuration  of  these 
structures;  if  the  cervical  vertebrse,  mastoid,  sternum,  lower 
jaw,  etc.,  are  not  diseased,  and  if  there  is  no  primary  actino- 
mycotic focus  in  the  lower  jaw,  the  swelling  is  not  an  abscess, 
but  a  neoplasm  or  an  aneurysm,  for  the  differentiation  of 
which  the  reader  is  referred  to  page  58. 


CHAPTER    X. 

TUMORS  OF  THE  NECK. 

LYMPHATIC  GLANDULAR  TUMORS. 

The  lymphatic  glandular  apparatus  may  be  affected  by 
a  variety  of  inflammatory  and  neoplastic  diseases  and  from 
macroscopic  appearance  the  differentiation  between  them  is 
often  extremely  difficult  and  at  times  even  impossible.  The 
difficulty  will  be  appreciated  when  it  is  remembered  that  the 
pathologist  is  often  unable  to  positively  determine  by  micro- 
scopic examination  the  exact  nature  of  the  diseased  process. 
The  trouble  lies  partly  in  our  imperfect  classification  of  the 
diseases  of  the  glandular  apparatus,  which  permits  clinicians 
to  group  under  one  nomenclature  entirely  different  types  of 
pathological  processes,  and  partly  in  the  fact  that  the  causa- 
tion of  some  of  the  glandular  diseases  is  still  very  little  under- 
stood. It  will  frequently  be  necessary  to  use  all  the  means 
at  our  disposal  in  order  to  arrive  at  a  correct  diagnosis  of  the 
abnormal  conditions  of  the  lymphatic  glandular  apparatus; 
this  includes  a  careful  antecedent  history  of  the  patient,  a 
thorough  physical  examination  of  the  internal  organs,  and  of 
the  region  which  is  drained  by  the  lymphatics  emptying  into  the 
enlarged  glands,  a  careful  blood  count  and  hsemoglobin  esti- 
mation, and,  finally,  in  cases  of  doubt,  an  excision  of  one  of  the 
glands  for  pathological  examination  and  animal  inoculation. 

While  this  chapter  is  to  be  especially  devoted  to  a  study 
of  the  diagnosis  of  and  differentiation  between  the  various 
diseased  conditions  of  the  cervical  lymph  glands,  it  is  to  be 
noted  that  what  is  true  of  these  glands  is  equally  true  of  the 
glands  in  other  regions.  It  is  more  difficult,  however,  to 
correctly  determine  the  nature  of  an  enlargement  of  the 
cervical  nodes  than  it  is  to  decide  upon  the  character  of 
diseased  conditions   of  the  glands  in  other  parts,  because 


TUMORS  OF  THE  NECK  131 

several  of  the  glandular  diseases  give  their  first  physical 
manifestations  in  an  enlargement  of  the  cervical  nodes,  and 
by  the  time  the  axillary,  inguinal,  mediastinal,  or  retro- 
peritoneal glands  become  appreciably  affected,  such  other 
constitutional  signs  of  the  malady  have  become  evidenced  as 
to  make  the  entire  clinical  picture  very  clear. 

The  glands  of  the  neck  may  be  roughly  divided  into  the 
superficial  and  deep  according  as  they  lie  above  or  behind 
the  deep  cervical  fascia.  The  deep  glands  are  again  arranged 
in  three  main  groups,  viz.,  those  of  the  submaxillary  region, 
those  between  the  anterior  border  of  the  sternocleidomastoid 
muscle  and  the  trachea,  and  those  in  the  occipital  triangle, 
the  latter  being  especially  numerous  in  the  supraclavicular 
fossa. 

Single  glands  of  these  groups  may  become  swollen  and  dis- 
eased, forming  smooth,  round  or  ovoid  tumors ;  or  a  number 
of  glands  of  one  group  or  an  entire  group  may  be  involved, 
forming  nodular  tumors,  the  size  and  conformity  of  which 
vary  with  the  number  of  glands  afi^ected;  or  all  the  groups 
of  one  or  both  sides  may  be  involved,  forming  single  or 
multiple  nodular  tumors  of  different  size  and  shape.  The 
consistency  of  glandular  tumors  varies  considerably,  depend- 
ing chiefly  on  the  nature  of  the  disease,  and  the  presence  or 
absence  of  periadenitis.  In  the  same  group  may  be  found 
soft  and  hard  and  fluctuating  nodules.  Pseudofluctuation  in 
very  soft  swellings  of  the  hyperplastic  type  is  often  to  be 
elicited. 

As  long  as  the  disease  is  confined  within  the  capsule  of  the 
gland  the  latter  remains  movable  under  the  skin  and  upon 
the  deeper  structures.  Periadenitis  results  in  its  becoming 
adherent  to  its  fellows,  to  the  deeper  structures,  and  to  the  skin. 

The  'presence  or  absence  of  a  periadenitis  may  be  taken  as 
a  basis  for  a  clinical  classification  of  diseased  glands.  Thus 
hyperplasia  without  periadenitis  may  be  due  to  (1)  a  local 
irritative  focus — e.  g.,  eczema,  local  infection,  etc.;  (2)  tuber- 
culosis; (3)  pseudoleuksemia;  (4)  leukaemia;  (5)  sarcoma; 
(6)  secondary  or  tertiary  stages  of  syphilis. 

Hyperplasia  with  periadenitis  may  be  due  to  (1)  tuber- 
culosis; (2)  carcinoma;  (3)  sarcoma;  (4)  initial  and  tertiary 
forms  of  syphilis. 


132      INJURIES  AND  DISEASES  OF  HEAD  AND   NECK 

Glandular  Enlargement  without  Periadenitis.  Simple 
Hyperplasia. — The  simple  hyperplasia  of  glands  occurs  most 
frequently  in  young  children  in  whom  diseases  of  the 
mouth,  tonsils,  and  gums  are  very  frequent,  but  it  may 
occur  at  all  ages  and  in  all  regions  of  the  body  from  a  local 
focus  of  irritation  and  infection.  Such  glandular  enlargement 
is  found  in  otherwise  healthy  subjects  and  subsides  when 
the  primary  focus  of  infection  or  irritation  has  been  done 
away  with. 

The  differentiation  of  this  condition  from  the  initial  stages 
of  tuberculous  hyperplasia  is  very  difficult  and  often  im- 
possible; for  such  swollen  glands  are  more  susceptible  to 
infection  with  tubercle  bacilli  than  healthy  ones,  and  there 
is  no  way  in  which  we  can  determine  when  the  simple  hyper- 
plasia becomes  tuberculous.  A  persistent  and  increasing 
glandular  enlargement  with  a  progressive  involvement  of 
new  nodes  after  the  subsidence  of  a  local  focus  of  infection 
or  irritation,  and  especially  if  periadenitis  develops  points 
very  strongly  to  tuberculosis,  and  even  more  so  when  there 
are  other  tuberculous  lesions  in  the  lungs,  bones,  etc.  From 
pseudoleuksemic  nodes  the  simple  hyperplastic  glands  are 
more  easily  differentiated.  In  the  former  there  is  no  local 
focus  of  infection,  the  enlargement  is  progressive,  new  nodes 
being  constantly  involved,  the  general  health  is  gradually 
impaired,  and  secondary  antemia  develops. 

Tuberculous  Hyperplasia. — Tuberculous  hyperplasia  without 
periadenitis  must  be  differentiated  from  simple  hyperplasia 
occurring  in  children  and  from  pseudoleuksemia  and  the 
secondary  and  tertiary  stages  of  syphilitic  glands. 

Clinical  evidences  in  favor  of  tuberculosis  are  the  presence 
of  other  foci  of  this  disease,  the  tendency  to  periadenitis  and 
softening  of  the  glands,  and  a  positive  response  to  a  tuberculin 
injection.  In  all  cases  of  doubt  a  single  node  should  be 
excised  and  submitted  to  microscopic  examination  and  animal 
inoculation. 

The  differentiation  of  tuberculous  from  simple  hyper- 
plasia has  been  considered  above. 

From  pseudoleuksemia  the  differential  diagnosis  is  often 
impossible,  and  always  very  difficult.  In  favor  of  the  latter 
are  the  absence  of  tuberculous  lesions  in  other  organs;  the 


TUMORS  OF   THE  NECK  133 

progressive  involvement  of  new  glands  in  the  neck,  axillae, 
groin,  etc.;  the  uniform  consistency  of  all  the  glands, 
deterioration  of  the  general  health,  the  presence  of  a  secondary 
ancemia,  and  the  improvement  which  may  follow  from 
internal  administration  of  arsenic. 

Leukemic  glands  are  easily  differentiated  from  tuber- 
culous ones  by  the  characteristic  blood  changes  that  attend 
this  malady.    (See  p.  42.) 

Fig.  65 


Scrofula.     Note  the  tuberculous  enlargement  of  the   cervical  lymph  nodes,  the 
rhagades  of  the  upper  lip,  the  chronic  nasal  catarrh,  and  the  conjunctivitis.   (Lexer.) 

Glandular  hyperplasise  occurring  in  the  secondary  and 
tertiary  periods  of  syphilis  are  distinguished  from  tuberculous 
glands  by  a  history  of  syphilis,  by  the  existence  of  other 
syphilitic  lesions  on  the  skin,  mucous  membranes,  etc.,  and 
by  their  disappearance  under  antispecific  treatment. 

Pseudoleukaemic  Hyperplasia. — Glandular  hyperplasia  due 
to  pseudoleuksemia  (malignant  Ivmphoma)  commences  as 
nodular,  uniformly  soft  enlargements  of  the  glands  on  one  or 
both  sides  of  the  neck.  The  glands  of  the  axillae,  groin, 
mediastinum,  retroperitoneum,  become  successively  enlarged; 
the  ones  first  affected  gradually  increase  in  size,  and  metas- 


134     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

tases  form  in  the  internal  organs.  In  the  latter  stages  of  the 
disease  a  marked  anaemia  and  general  physical  deterioration 
develop.  The  glands  are  never  fixed  and  there  is  no  differ- 
ence in  the  consistency  of  different  parts  of  the  tumors. 

Fig.  66 


Pseudoleukaemic  glands  of  the  neck.    Uniformly  soft,  movable  tnmors. 


The  glandular  enlargement  due  to  leukaemia  resembles 
that  due  to  pseudoleuksemia.  But  in  the  former  the  blood 
shows  decided  changes  (see  p.  35),  the  spleen  is  enlarged  and 
the  anaemia  is  intense. 

The  differentiation  from  simple  and  tuberculous  hyper- 
plasia has  already  been  considered.     It  is  to  be  noted  that 


TUMORS  OF   THE  NECK 


135 


tuberculous  and  pseudoleukaemic  hyperplasia  may  exist  side 
by  side  in  the  same  individual. 

From  leukaemic  hyperplasia  these  glandular  enlargements 
are  distinguished  clinically  by  a  late  appearance  of  antemia 
and  an  early  manifestation  of  the  glandular  tumors,  whereas 


Fig.  67 


Lymphosarcoma  in  a  woman  twenty-five  years  of  age.    Note  the  regular  margins  ot 
the  ulcer  and  fungous  granulations  of  the  base.    (Von  Bergmann.) 


in  leukaemia  the  anaemia  appears  first  and  the  glandular 
enlargement  later.  An  examination  of  the  blood  at  once 
decides  the  diagnosis.     (See  p.  39.) 

Sarcomatous  Hyperplasia. — Sarcoma  of  the  cervical  glands 
starts  either  in  the  nodes   along    the  carotid  vessels  or  in 


136     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

the  nodes  below  and  behind  the  angle  of  the  lower  jaw. 
The  tumor  is  smooth,  of  uniform  consistency,  and  movable 
in  its  early  stages ;  later  it  becomes  softer  in  some  of  its  parts, 
fixed  to  the  skin  and  deeper  structures,  and  eventually  it 
ulcerates  through  its  cutaneous  covering.  In  its  early  stages 
sarcoma  cannot  be  macroscopically  differentiated  from 
pseudoleuksemia.  Sarcomatous  glands  usually  grow  rapidly, 
but  those  behind  the  jaw  may  be  of  very  slow  growth. 
Pseudoleukajmic  glands  are  always  movable  and  never 
soften  or  ulcerate,  whereas  sarcomatous  glands  soon  become 
fixed,  and  finally  soften  and  ulcerate.  Microscopic  exami- 
nation will  aid  in  making  an  early  diagnosis. 

Syphilitic  Hyperplasia. — Syphilitic  hyperplasia  of  the  glands 
during  the  secondary  stages  is  readily  recognized  by  the 
anamnesis  and  the  presence  of  other  syphilitic  lesions  of 
the  skin  and  mucous  membranes.  Gummata  of  the  glands, 
a  rare  condition,  form  smooth  elastic  tumors  which  remain 
movable  unless  degeneration  occurs,  in  which  case  they 
soften,  break  down,  become  fixed,  and  ulcerate.  Before 
degeneration,  the  history,  the  otherwise  good  health  (no 
tuberculosis)  of  the  individual,  the  absence  of  other  glandular 
enlargement,  and  the  absence  of  progression  to  other  glands 
are  sufficient  to  distinguish  these  glandular  enlargements 
from  those  due  to  tuberculosis,  sarcoma,  and  pseudoleuksemia. 
In  the  ulcerating  stages  the  differentiation  must  be  made 
from   actinomycosis   and  tuberculosis.     (See  p.  42.) 

Glandular  Enlargement  with  Periadenitis. — The  diag- 
nosis of  the  cause  of  the  enlargement  of  glands  which  are 
surrounded  by  a  periadenitis  and  fused  together  into  irreg- 
ular masses  more  or  less  fixed  upon  the  deeper  structures 
and  skin  is  usually  easy. 

Tuberculosis. — In  tuberculosis  at  this  stage  of  the  disease  the 
glandular  masses  are  soft  in  some  spots  and  fluctuating  in 
others,  there  are  usually  other  evidences  of  tuberculosis .  in 
the  lungs,  bones,  or  internal  viscera,  and  there  may  be  scars 
of  healed  tuberculous  abscesses  in  the  neck  or  in  other  parts 
of  the  body.  Such  scars  are  irregular  in  form,  broad,  show 
depressions  and  elevations,  and  are  adherent  to  the  underlying 
structures.  If  the  glands  are  ulcerated  the  ulcers  are  irregular 
and  worm-eaten  and  covered  by  fungous  granulations. 


TUMORS  OF   THE  NECK  137 

Lymphosarcoma. — In  lymphosarcoma  there  is  a  single  tumor 
made  up  of  many  irregular  nodules,  the  soft,  pseudofluctuating 
consistency  of  which  is  uniform.  The  tumor  grows  rapidly, 
attains  considerable  size,  compresses  the  neighboring  struct- 
ures, and  causes  rapid  deterioration  of  the  general  health. 
Metastases  in  distant  organs  are  frequently  found.  After 
ulceration  the  defect  is  surrounded  by  more  regular  margins 
and  the  base  is  covered  by  easily  bleeding,  sloughing  granula- 
tions. Microscopic  examination  at  once  reveals  the  nature 
of  the  malady. 

Carcinoma. — Carcinomatous  glands  are  always  secondary 
to  a  primary  focus  of  the  disease  in  the  face  or  oropharynx. 
The  glands  are  uniformly  hard;  after  ulceration  the  defect  is 
surrounded  by  everted,  hard  edges,  and  the  base  is  covered 
by  reddish,  easily  bleeding,  crusting  granulations.  In  old  age 
a  tuberculous  gland  with  hard,  calcareous  capsule  may  sim- 
ulate a  carcinomatous  nodule,  but  careful  search  shows  no 
primary  growth,  and  carcinomatous  glands  are  always  fixed. 

Glandular  Enlargement  Accompanjring  Sjrphilis. — The  gland- 
ular enlargement  which  accompanies  the  primary  stage  of 
syphilis  is  always  attendant  upon  an  initial  sore.  The 
swelling  attains  its  maximum  size  rapidly,  and  disappears 
after  the  use  of  mercury.  Breaking  down  and  ulcerating 
gummata  of  the  neck  have  been  considered  on  page  126. 


MISCELLANEOUS  TUMORS. 

For  the  purposes  of  diagnostic  study  we  may  group  these 
tumors  into  those  of  solid  consistency  and  those  with  fluid 
contents.  The  former  are  similar  histologically  to  the  benign 
and  malign  solid  tumors  which  arise  from  connective  and 
epithelial  tissues  in  other  parts  of  the  body,  but  the  latter 
are,  for  the  most  part,  unique  tumors  to  this  region. 

Fluid  Tumors. — These  are  wholly  or  in  part  fluctuating 
and  elastic.  In  this  class  belong  the  branchiogenetic  cysts, 
the  congenital  cystic  hygroma  or  lymphangioma,  the 
acquired  cavernous  lymphangioma,  the  enlarged  bursse, 
the  echinococcus  cysts,  the  blood  cysts,  the  hsemangioma, 
the  cavernous  angioma,  and  the  aneurysms. 


138     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

These  may  be  again  grouped  according  as  the  contents 
are  cystic  material  or  blood.  If  the  tumor  is  compressible, 
it  is  a  blood-containing  one,  and  is  therefore  a  blood  cyst, 
an  angioma,  or  an  aneurysm.  It  is  to  be  noted,  however, 
that  not  every  blood-containing  tumor  is  compressible — e.  g., 
a  blood  cyst  whose  communication  with  the  vein  from  which 


Mullilocular  branchiogenic  cyst.    i,Von  Bruus.) 

it  arises  has  become  closed.  In  the  absence  of  compressibility 
other  clinical  evidences  often  aid  us  in  the  recognition  of 
blood  tumors.  Thus,  an  expansile  pulsation  in  a  tumor 
points  to  its  aneurysmal  character;  likewise  systolic  bruit, 
and  increase  or  decrease  in  its  size  when  the  efferent  or 
afferent  vessels  are  respectively  compressed.    Should  all  the 


TUMORS  OF   THE  NECK 


139 


data  we  can  collect  be  insufficient  to  enable  us  to  make  a 
diagnosis,  then  aseptic  puncture  with  a  fine  needle  will  afford 
conclusive  evidence  as  to  the  contents  of  a  fluid  tumor. 

Cystic  Tumors.  1.  Branchiogenetic  Cysts. — The  branchio- 
genetic  cysts  are  rarely  noticed  at  birth;  they  develop  chiefly 
in  the  first  three  decennials  of  life,  and  especially  at  puberty. 
They  either  have  a  lateral  position  between  the  sternocleido- 
mastoid muscle  and  the  median  line  anywhere  from  the 
mastoid  process  down  to  the  jugulum,  sometimes  attached  to 

Fig.  69 


Lateral  branchial  cj'st.    (DeuDis.) 

the  lower  jaw,  to  the  hyoid  bone  or  styloid  process,  or  they 
have  a  median  position  above  or  below  the  hyoid  bone. 

The  lateral  cysts  arise  from  the  second  branchial  cleft, 
the  median  from  the  thyroglossal  duct  and  sinus  cervicalis. 
They  are  due  to  closure  of  the  orifices  of  a  complete  or 
incomplete  branchial  fistula  or  to  the  persistence  of  the 
branchial  canal  or  to  cell  inclusions  during  the  closure  of 
the  sinus  cervicalis  (the  latter  forming  median  dermoid 
cysts). 


140     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

The  contents  of  these  cysts  are  either  a  serous  fluid,  in  which 
case  they  are  known  as  hygromata,  or  a  mucoid  material,  or 
an  oily,  fatty  material  with  hair,  teeth,  bones,  etc.,  in  which 
case  they  are  laiown  as  dermoid  cysts. 

They  form  ovoid,  hen's -egg-sized,  usually  fluctuating  and 
elastic,  unilocular  or  multilocular  tumors,  which  are  movable 
under  the  skin,  but  less  movable  on  the  deeper  parts,  and 
are  not  tender.  The  overlying  skin  is  of  normal  appearance. 
They  grow  slowly  and  compress  the  neighboring  structures. 

Fig.  70 


Lateral  branchial  cyst.    (Dennis.)    (Side  view  of  Fig.  69.) 


The  lateral  cysts  must  be  differentiated  from  cystic  lymph 
angioma  and  aberrant  thyroid  cysts,  and  the  median  ones 
from  enlarged  bursse  that  lie  above  or  below  the  hyoid  bone, 
and  from  chronic  glandular  abscess. 

The  cystic  lymph  angioma  are  multilocular,  lobulated, 
flaccid,  congenital  tumors  of  larger  size  and  more  rapid 
growth;  they  are  more  superficial  and  on  aspiration  yield  a 


TUMORS  OF   THE  NECK 
Fig.  71 


141 


Dermoid  cyst  at  base  of  tongue.    (Marehant.) 
Fig.  72  Fig.  73 


Median  suprahyoid  dermoid  cysts. 


142     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

clear,  serous,  milky,  or  brownish  fluid  which  coagulates  on 
standing.  Aberrant  thyroid  cysts  and  enlarged  suprahyoid 
and  infrahyoid  bursse  can  only  be  differentiated  from  bran- 
chial and  dermoid  cysts  by  a  microscopic  examination.  A 
chronic  glandular  abscess  is  slower  in  its  development  than 
is  a  dermoid  cyst;  aspiration  yields  pus,  and  there  are  likely 
to  be  other  glandular  nodes. 

Fig.  74 


Dermoid  of  the  floor  of  the  mouth.    (Von  Bergmann.) 

2.  Congenital  Cystic  Hygroma. — Congenital  cystic  hygroma 
or  lymphangioma  is  due  to  a  progressive  dilatation  of  the 
lymphatic  vessels.  It  is  most  frequently  located  in  the 
subcutaneous  fatty  tissue,  whence  it  invades  the  deeper  parts, 
but  it  may  be  primary  in  the  deep  tissues,  especially  in  the 
carotid  sheath,  and  gradually  extend  to  the  surface.  It  is 
met  with  in  very  young  children  and  in  infants  and  com- 
mences, as  a  rule,  in  the  upper  cervical  region  in  front  of  or 
behind  the  sternocleidomastoid  muscle,  and  grows  fairly 
rapidly  upward  and  downward,  penetrating  everywhere 
between  the  various  structures  and  compressing  them. 


TUMORS  OF  THE  NECK 


143 


It  forms  a  fluctuating,  usually  flaccid,  lobulated  tumor. 
The  overlying  skin  is  movable,  at  times  so  thinned  as  to  be 
translucent,  but  again  thickened  and  oedematous  (elephant- 
iasis).    The  superficial  veins  are  enlarged. 

Aspiration  yields  a  clear,  serous,  milky,  or  brownish  fluid 
which  coagulates  on  standing. 

Their  differentiation  from  branchial  cysts  has  already  been 
discussed.    Accessory  thyroid  cysts  are  not  lobulated  and  do 


Fig.  75 


Congenital  cystic  hygroma. 


not  yield  a  coagulating  fluid  on  aspiration.  Deep  branching 
lipomata  are  not  truly  fluctuating,  do  not  yield  the  character- 
istic fluid  on  aspiration,  and  are  much  more  deeply  situated. 
3.  Cavernous  Lymphangioma. — Cavernous  lymphangioma 
is  a  rare  tumor  and  develops  during  adult  life.  As  the  pre- 
ceding growth,  it  is  due  to  a  progressive  dilatation  of  the 
lymphatic  vessels  and  usually  commences  in  the  lower 
carotid  triangle.     It  forms  a  lobulated,  fluctuating,  flaccid 


144     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

tumor  in  front  of  or  behind  the  sternocleidomastoid  muscle; 
aspiration  yields  a  clear  or  milky  fluid  which  coagulates  on 
standing.  These  characteristics  are  usually  sufficient  to 
differentiate  it  from  a  branchial  cyst,  or  deep  lipoma,  or 
cavernous  angioma. 

4.  Enlarged  Bursse. — Enlarged  bursse  (hygroma),  either 
suprahyoid  or  infrahyoid,  are  only  occasionally  met  with.  The 
tumor  develops  slowly  and  painlessly;  rarely  becomes  larger 
than  a  walnut;  is  rounded  and  fluctuating,  and  is  fixed  to 
the  hyoid  bone,  but  movable  under  a  normal-appearing  skin. 
Only  by  microscopic  examination  can  it  be  differentiated 
from  a  median  branchial  cyst,  or  an  accessory  thyroid  cyst. 
When  these  bursse  become  acutely  inflamed  and  suppurate 
they  are  to  be  distinguished  from  suppurating  lymphatic 
glands  by  their  more  acute  course  and  greater  tenderness. 

5.  Echinococcus  Cysts. — Echinococcus  cysts  of  the  neck  are 
rare.  They  are,  for  the  most  part,  situated  under  the  sterno- 
cleidomastoid muscle,  and  are  characterized  by  an  inter- 
mittent increase  in  size.  The  cyst  is  smooth  and  fluctuating; 
aspiration  thereof  yields  a  clear  or  turbid,  serous  fluid  which 
does  not  coagulate,  and  which,  under  the  microscope,  may 
show  the  booklets  of  the  echinococcus. 

The  diagnosis  from  other  cysts  of  the  neck  is  exceedingly 
difficult,  and  will  usually  be  made  only  after  incision. 
Lymphatic  cysts  are  to  be  differentiated  by  their  coagulating 
contents,  subfacial  lipoma  by  their  solid  consistency. 

Blood  Tumors.  1.  Blood  Cysts.— Blood  cysts  are  of  un- 
certain pathogenesis.  They  are  either  congenital  or  first 
appear  in  adult  life,  especially  on  left  side  of  the  neck,  and 
vary  in  size  from  a  walnut  to  a  child's  head.  They  form 
smooth  or  slightly  lobulated,  fluctuating,  elastic  tumors, 
which  are  movable  under  a  normally  appearing  skin,  and 
upon  the  deeper  parts.  The  tumor  is  compressible  only 
when  it  communicates  with  a  large  vein,  and  in  such  cases 
its  tension  increases  on  coughing  and  straining. 

These  cysts  which  are  compressible  and  fluctuating  are 
easily  recognized.  Non-compressible  fluctuating  tumors  are 
to  be  distinguished  from  subfacial  lipoma,  cold  abscesses,  and 
soft  malignant  tumors  by  aspiration.  From  aneurysm  they 
differ  in  their  lack  of  expansile  pulsation. 


TUMORS  OF   THE  NECK  145 

2.  Angiomata. — Angiomata  of  the  simple  type  occur  in  the 
form  of  flat  vascular  nsevi,  and  also  as  subcutaneous  tumors  in 
any  part  of  the  neck;  their  diagnosis  is  self-evident.  The 
cavernous  angioma  is  usually  connected  only  with  the  veins, 
but  may  be  in  communication  with  the  arteries,  in  which  case 
the  tumor  has  expansile  pulsation.  The  tumors  are  flat  and 
irregular,  not  truly  fluctuating,  but  are  compressible,  and 
their  tension  is  increased  by  straining  and  coughing. 

Their  compressibility  and  pseudofluctuation  are  sufiicient 
to  distinguish  them  from  blood  cysts  and  other  forms  of  cystic 
growths.  Deep-seated  cavernoma  are  difiicult  to  diagnose, 
because  their  physical  characteristics  cannot  be  elicited. 

3.  Aneurysms. — True  and  false  and  arteriovenous  aneu- 
rysms of  the  neck  are  of  frequent  occurrence  and  give  suffi- 
ciently clear  signs  to  render  their  diagnosis  easy  in  the  great 
majority  of  cases. 

They  form  expansile,  pulsating  tumors  that  are  usually 
compressible,  that  increase  in  size  when  the  efferent  vessel 
is  compressed,  and  that  afford,  on  auscultation  and  palpation 
respectively,  a  systolic  murmur  and  a  thrill. 

As  the  tumor  grows  it  compresses  the  neighboring  struct- 
ures; compression  of  the  recurrent  laryngeal  nerve  gives  rise 
to  aphonia  or  hoarseness  from  paralysis  of  the  abductor 
muscle  of  the  vocal  cord,  the  cord  resting  in  the  cadaveric 
position;  compression  of  the  sympathetic  results  in  dilatation 
of  the  pupil  on  the  same  side.  Pressure  upon  the  trachea 
and  oesophagus  occasions  tracheal  stridor,  dyspnoea,  and 
dysphagia.  Depending  upon  the  position  of  the  aneurysm 
there  will  be  manifest  inequality  and  retardation  in  the 
temporal  or  radial  pulses. 

An  abscess,  neoplasm  or  tumor,  lying  upon  a  large  artery, 
may  pulsate  upward  and  downward,  but,  with  one  exception, 
they  never  have  expansile  pulsation.  The  exception  is  a 
very  vascular  neoplasm,  but  this  grows  more  rapidly  than 
an  aneurysm,  does  not  retard  the  pulses,  and  is  not  com- 
pressible to  the  extent  of  aneurysms.  A  thyroid  tumor  lying 
upon  the  carotid  may  pulsate,  but  not  in  expansile  fashion 
(except  in  case  of  aneurysmal  goitre,  and  this  is  truly  a 
variety  of  aneurysm),  and  rises  and  falls  with  deglutition, 
which  aneurysms  never  do. 

10 


146      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Cavernous  angiomata  connected  with  an  artery,  if  they  are 
deeply  seated,  cannot  be  difyerentiated  from  aneurysms,  for 
they  have  all  the  physical  characteristics  of  the  latter  and 
are  in  fact  aneurysmal  tumors. 

It  is  a  matter  of  surgical  importance  to  determine  the  point 
of  origin  of  the  aneurysm.  Those  that  spring  from  the  carotid 
in  the  neck,  or  from  the  subclavian  in  the  posterior  triangle, 
are  easily  located;  those  that  arise  from  the  innominate,  or 
from  the  first  portion  of  the  subclavian  and  carotid,  must  be 
placed  by  a  study  of  the  radial  and  temporal  pulses.  If  the 
temporal  pulses  are  the  same,  the  aneurysm  is  neither 
innominate  nor  carotid;  if  the  radial  pulses  are  the  same, 
the  aneursym  is  neither  innominate  nor  subclavian.  Thus 
by  exclusion  the  starting  point  or  origin  of  the  aneurysm 
can  be  determined. 


SOLID  TUMORS  OF  THE  NECK. 

Some  of  these  have  already  been  considered  under  gland- 
ular tumors,  for  which  the  reader  is  referred  to  page  130. 

In  the  newborn,  a  hoematoma  of  the  sternocleidomastoid 
muscle,  or  a  rupture  of  this  muscle,  manifests  itself  by  a  soft, 
doughy  tumor,  somewhat  tender  and  causing  the  infant  to 
hold  the  head  laterally  flexed  and  rotated  to  the  opposite 
side.     Such  tumors  can  be  confused  with  nothing  else. 

Fibromata. — Fibromata  may  be  superficially  or  deeply 
situated  in  any  part  of  the  neck.  Their  hard  consistency 
differentiates  them  from  lipomata,  while  their  slow  growth 
distinguishes  them  from  sarcomata. 

Lipomata. — Lipomata  are  likewise  either  superficial  or 
deep,  the  former  being  especially  common  on  the  back  of 
the  neck,  where  they  form  comparatively  large,  lobulated, 
soft,  slowly  growing  tumors. 

The  deep  lipomata  of  the  neck  are  much  less  frequently 
met  with.  They  originate  in  the  subfascial  layers,  and  pene- 
trate in  a  dendritic  fashion  between  all  the  structures  and  into 
the  mediastinum.  In  its  diffuse  character  it  resembles  a 
malignant  growth,  but  is  not  adherent,  and  if  thoroughly 
removed  in  all  its  parts  it  does  not  recur. 


PLATE  I. 


Hsematoma  of  the  Sternomastoid  Muscle  of  the  Right  Side 
in  a  Ne^Afborn  Infant.  S^A^elling  at  the  centre  of  the  anterior 
border  of  the  nnusele;  contraction  of  the  muscle  vv^ith 
torticollis.    (Koplik.) 


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TUMORS  OF   THE  NECK 


147 


The  diagnosis  of  these  deep  hpomata  is  always  difficult; 
their  soft,  pseudofluctuating  consistency  may  lead  to  their 
being  mistaken  for  cystic  or  blood  tumors,  from  which  they 
can  only  be  differentiated  by  aseptic  aspiration.  From  soft, 
malignant  neoplasms  they  can  only  be  differentiated  when 
they  are  exposed  on  the  operating  table. 


Fig.  76 


Lipoma  of  the  neck.    (Von  Bergmann.) 


Cervical  Rib. — Occasionally  a  patient  will  complain  of 
neuralgic  pains  in  the  shoulder,  arm,  and  forearm — i.  e.,  in 
the  region  of  distribution  of  the  brachial  plexus — and  on 
examination  a  hard,  fixed  tumor  is  felt  in  the  supraclavicular 
*  region,  usually  on  one  side,  but  at  times  bilaterally.  The 
general  health  is  not  impaired;  the  tumor  does  not  grow, 
and  it  is  somewhat  tender.  A  cervical  rib  should  be  suspected 
and  an  x-ray  examination  ordered. 


148     INJURIES  AND   DISEASES  OF  HEAD  AND  NECK 

Malignant  Growths. — Of  malignant  growths,  sarcoma  of 
the  glands  has  been  considered.  Primary  carcinoma  may 
originate  in  the  remains  of  the  branchial  canal  and  manifest 
itself  as  a  hard  nodule  in  the  carotid  triangle,  circumscribed 
at  first,  but  growing  rapidly  and  infiltrating  the  neighboring 


Fig 


Difiuse  lipoma  of  the  ueck.    (Von  Bruns.) 

structures,  and  causing  pain  which  radiates  into  the  ears  and 
occiput.  Glandular  enlargement  and  ulceration  follow  early. 
The  diagnosis  is  made  from  the  evident  character  of 
malignancy  in  the  neoplasm,  and  by  the  absence  of  a  primary 
carcinoma  in  the  mouth,  oropharynx,  oesophagus  or  larynx, 
to  account  for  the  glandular  involvement. 


TUMORS  OF   THE  NECK 


149 


THYROID  TUMORS. 

Tumors  of  the  neck  are  of  thyroid  origin  if  they  occupy 
the  region  of  the  thyroid  gland,  he  behind  the  sternohyoid 
and  sternothyroid  muscles,  and  move  up  and  down  with 
deglutition.  It  is  to  be  especially  noted,  however,  that 
aberrant  (accessory)  thyroid  lobes  are  sometimes  present  on 

Fig.  78 


Thyroid  tumor  springing  from  the  tip  of  the  upper  pole  of  the  thyroid  gland.    It 
occupies  the  same  position  as  would  an  aberrant  thyroid  tumor. 


the  side  of  the  thyroid  cartilage,  or  beneath  the  outer  edge  of 
the  sternocleidomastoid  muscle,  or  behind  the  sternum,  and 
that  tumors  developing  in  these  aberrant  lobes  do  not  have 
these  physical  characteristics.  The  character  of  such  tumors 
can  only  be  determined  by  microscopic  examination;  their 


150     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Fig.  79 


Diagram  of  accessory  thyroids.    (Von  Bergmann.) 
Fig.  80 


Intrathoracic  thyroid  :  TSD,  right  superior  thyroid  artery  ;  TSS,  left  superior  thyroid 
artery.    (Von  Bergmann.) 


TUMORS  OF   THE  NECK 


151 


thyroid  origin  can  only  be  suspected,  but  never  positively 
determined,  before  their  removal. 


Fig.  81 


Parenchymatous  stroma.    (Von  Bergmann.) 

Nature  of  Thyroid  Tumors. — The  nature  of  a  thyroid 
tumor  is  determined  from  its  rapidity  of  growth,  its  outline, 


152      INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Tig.  82 


Cystic  goitre.    A  single,  rounded,  circumscribed  nodule,  having  distinct  fluctuation. 

Fig.  83 


Struma  in  Graves'  disease.    (Von  Bergmann.) 


TUMORS  OF   THE  NECK  153 

whether  it  involves  the  whole  or  part  of  the  gland,  its  con- 
sistency, its  mobility,  its  pulsation,  and  its  encapsulation. 

If  the  whole  gland  is  uniformly  and  symmetrically  enlarged 
and  soft,  or  contains  numerous  small  nodules,  the  tumor  is 
a  parenchymatous  goitre. 

If  the  whole  gland  is  enlarged  and  soft  and  vascular,  or 
contains  several  small  nodules,  and  there  are  tachycardia, 
exophthalmos,  inco-ordination  of  associated  movements  of  the 
eyeball,  eyelid  and  brows,  together  with  nervousness,  etc., 
the  tumor  is  a  manifestation  of  Graves'  disease. 


Fig.  84 


Follicular  goitre.    (Von  Bruns.) 

If  the  gland  contains  one  or  more  rounded,  sharply  circum- 
scribed nodules,  it  is  an  adenomatous  goitre.  Such  adeno- 
matous nodules  may  undergo  degeneration  and  become 
cystic  (fluctuating)  or  hyaline  (soft  and  doughy)  or  calcareous 
(stony,  hard) .  In  the  same  gland,  one  type  or  several  types  of 
degenerated  nodules  may  be  present. 

If  the  tumor  is  made  up  chiefly  of  enlarged  and  dilated 
veins  and  arteries  (it  being  compressible  and  having  expansile 
pulsation  and  affording  a  systolic  bruit)  it  is  a  vascular  goitre 


154     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Expansile  pulsation  is  present  only  when  numerous  arteries 
go  to  make  up  the  tumor. 

If  the  tumor  begins  in  one  lobe,  is  hard  and  increases  in 
size  rapidly  and  infiltrates  the  rest  of  the  gland,  it  is  raalig- 
nant,  either  sarcoma  or  carcinoma.    Pain  shooting  up  to  the 

Fig.  85 


Colloid  goitre.    (Von.  Bruns.) 


ears  and  secondary  growths    in  the  bones  and  glands  are 
confirmatory  evidences  of  malignancy. 

One  should  never  end  his  examination  of  a  thyroid  tumor 
until  he  has  looked  for  evidences  of  thyroidism,  such  as 
tachycardia,  tremors,  nervousness,  etc.;  inspected  the  vocal 
cords    and   observed   their   movements,    and   palpated   the 


TUMORS  OF   THE  NECK 


155 


trachea  and  large  vessels  in  the  neck.     For  the  presence  or 
absence  of  thyroidism,  paralysis  of  the  cords  and  compression 


Fig.  86 


Carcinoma  of  thyroid  gland.    (Curschmann.) 


of  the  trachea  are  most  important  data  for  the  surgeon  to 
know  prior  to  operative  interference. 


156     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 


FISTULA  AND  SINUSES  OF  THE  NECK. 

If  a  branchial  cyst  becomes  infected  and  perforates  ex- 
ternally, or  if  on  account  of  a  wrong  diagnosis  it  is  simply 

Fig.  87 


A,  lateral  sinus  ;  B,  median  sinus.    (Von  Bergmann.) 


incised  without  complete  removal  of  its  walls,  a  fistula  will 
result.  If  the  opening  of  the  fistula  is  in  tile  median  line 
of  the  neck,  and  if  the  tract  thereof  extends  up  to  the  hyoid 
bone  and  root  of  the  tongue,  we  have  to  do  with  a  median 
branchial  cyst  that  originated  in  a  patent  thyroglossal  duct. 
If,  on  the  other  hand,  the  sinus  opens  directly  above  the 
sternoclavicular  joint  and  runs  upward  and  outward  to  open 
at  the  pillar  of  the  fauces,  we  have  to  do  with  a  lateral 
branchial  cyst  that  devoloped  from  the  branchial  canal. 
The  external  opening  of  these  latter  fistulse  is  sometimes 


TUMORS  OF   THE  NECK 


157 


situated  beneath  a  little  pendulous  fold  of  skin  enclosing  a 
bit  of  cartilage;  it  may  be  located  in  the  tragus  or  helix  of 
the  ear. 

Fig.  88 


Incomplete  lateral  fistula.    (Watson.) 


CHAPTER  XL 

DISEASES   OF  THE  LARYNX:  FOREIGN  BODIES  IN  THE 
LARYNX  AND  BRONCHI. 

The  local  treatment  of  diseases  of  the  larynx  requires 
special  training  and  technique  which  only  those  who  intend 
to  devote  themselves  to  this  field  of  medicine  need  acquire. 
But  neither  the  general  practitioner  nor  the  surgeon  can 
afford  to  neglect  or  fail  to  cultivate  the  simple  methods 
which  are  employed  in  the  examination  of  this  organ,  and 
by  the  use  of  which  alone  a  correct  diagnosis  of  the  diseases 
of  this  part  can  be  made.  Intimately  concerned  as  this 
organ  is  with  the  every-day  life,  yes,  even  with  the  very 
existence  of  the  individual,  its  slightest  abnormality  of 
function  is  at  once  detected  and  brought  to  the  attention 
of  the  physician,  whose  duty  it  is  to  recognize  the  nature  of 
the  malady.  The  technique  which  is  necessary  for  making 
a  laryngoscopic  examination  is  readily  acquired  and  the 
observer  soon  learns  to  recognize  the  normal  aspect  of  the 
parts  and  the  significance  of  the  typical  abnormalities  thereof. 
Only  in  the  atypical  manifestations  of  diseased  processes  is 
difficulty  in  diagnosis  encountered,  and  in  these  instances  the 
specially  trained  eye  and  the  pathologist's  examination  of 
sections  of  the  diseased  tissue  should  be  early  called  upon  to 
aid  in  the  interpretation. 

Method  of  Laryngoscopic  Examination. — ^The  essentials 
for  a  laryngoscopic  examination  are  a  good  light,  a  forehead 
mirror,  and  a  laryngoscopic  mirror.  The  patient  should. sit 
upright  in  front  of  the  examiner,  grasp  his  own  tongue  with 
a  small  napkin  and  draw  it  well  forward.  With  the  forehead 
mirror  the  light  which  comes  from  behind  the  shoulder  of  the 
patient  is  focused  upon  his  uvula  and  soft  palate.  The 
laryngoscopic  mirror,  which  has  been  just  previously  gently 
warmed  over  the  light,  is  then  introduced  up  to  the  uvula 


DISEASES  OF   THE  LARYNX 


159 


without  touching  the  tongue,  and  while  the  patient  phonates  e 
the  picture  of  the  larynx  is  observed. 

Visual  inspection  of  the  exterior  of  the  organ,  together 
with    external    and    pharyngeal    palpation,    and    in    some 


Ftg. 


w 


^ 

\ 


Laryngeal  mirror  in  position,  displaying  the  laryngeal  image.    (Cohen.) 

instances  sounding  of  the  laryngeal  canal,  also  afford  valuable 
clinical  data  upon  which  to  base  a  diagnosis  of  injury  or 
disease  of  this  part. 


160     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

Manifestations  of  Diseases  of  the  Larynx. — Diseases  of 
the  larynx  manifest  their  presence  by  signs  which  indicate  an 
interference  with  its  functions,  viz.,  that  of  a  tube  carrying  air 
to  the  lungs,  and  that  of  an  organ  of  phonation;  alterations 
in  the  normal  external  and  internal  appearances  and  feel  of 
the  organs  are  further  evidences  of  its  disease. 

No  one  who  has  witnessed  an  interference  with  the  air- 
carrying  function  of  the  larynx  sufficient  to  cause  air  hunger 
can  ever  forget  the  tragic  picture  which  is  afforded  by  the 
unfortunate  individual.  The  early  struggles  for  air,  the 
forced  action  of  the  respiratory  muscles,  the  tugging  at  the 
throat,  the  marked  retraction  of  the  supraclavicular  spaces 
and  epigastrium  with  each  inspiration,  the  play  of  the  alse 
nasi,  the  cyanosis,  and  the  loud,  stridulous  respiration.  More 
or  less  rapidly,  depending  on  the  degree  of  stenosis,  the 
struggles  cease,  the  respiration  becomes  shallower  and  less 
audible,  the  cyanosis  more  marked,  the  pulse  more  feeble 
and  rapid,  until  death  puts  an  end  to  the  scene. 

Such  laryngeal  dyspnoea  is  to  be  differentiated  from 
bronchial,  pulmonary,  or  cardiac  dyspnoea.  The  air  hunger 
in  these  latter  conditions  may  be  just  as  marked,  but  their 
is  no  stridulous  respiration,  there  is  no  huskiness  of  the  voice, 
no  laryngeal  cough,  and  physical  examination  reveals  in  the 
bronchi  or  air  cells  of  the  lung  or  in  the  heart  evidences  of 
disease  which  account  for  the  dyspnoea.  The  differentiation 
is  most  important  from  a  therapeutic  point  of  view.  No 
patient  should  be  permitted  to  succumb  to  laryngeal  dyspnoea 
if  a  physician  is  in  attendance,  no  matter  how  primitive  the 
instruments  at  his  disposal  for  the  performance  of  trache- 
otomy. Naturally  in  such  cases  the  high  operation  is  the 
only  one  to  perform,  for  this  can  be  done  rapidly  even  by 
inexpert  surgeons.  On  the  other  hand,  tracheotomy  does  no 
good  for  bronchial,  pulmonic,  or  cardiac  dyspnoea,  except 
when  it  is  due  to  foreign  bodies  in  the  bronchi.^ 

1  I  was  recently  urgently  summoned  to  the  hospital  to  perform  tracheotomy 
upon  a  patient  who  was  suffering  with  severe  dyspnoea,  owing,  I  was  told,  to 
compression  of  the  trachea  by  a  cervical  neoplasm.  The  dyspnoea  being  ex- 
treme, the  house  surgeon  proceeded  to  operate  before  my  arrival.  He  intended  to 
make  a  low  tracfieolomy.  I  found  him  considerably  bothered  by  a  profuse  venous 
hemorrhage  from  the  soft  parts  overlying  the  trachea,  and  as  he  had  diflaculty  in 
checking  this,  I  rapidly  prepared  my  hands  and  assisted  him.    After  stopping  the 


DISEASES  OF   THE  LARYNX  161 


ACUTE  LARYNGEAL  DISEASES. 

In  the  acute  laryngeal  diseases  the  dyspnoea  and  stridor 
are  the  most  striking  symptoms,  but  no  less  important  for 
diagnosis  are  the  huskiness  of  the  voice,  aphonia,  and  char- 
acteristic metallic  laryngeal  cough.  In  the  urgent  cases  of 
dyspnoea  no  time  is  afforded  for  laryngoscopic  or  even  visual 
inspection  of  the  parts  in  these  cases.  The  diagnosis  will  have 
to  be  made  from  a  rapidly  taken  anamnesis  and  a  hurried 
physical  examination.  In  the  less  urgent  acute  cases,  and 
in  the  chronic  laryngeal  maladies,  which,  by  the  way,  give 
the  first  evidences  of  their  presence  by  changes  in  the  char- 
acter of  the  voice,  and  by  pain,  and  only  later  on  by  dyspnoea, 
there  is  ample  time  for  laryngoscopic  and  general  physical 
examination. 

Causes  of  Acute  Laryngeal  Stenosis. — The  causes  of 
acute  laryngeal  stenosis  are:  Acute  laryngitis,  diphtheritic 
laryngitis  (croup) ,laryngismiis  stridulus  (spasm  of  the  larynx), 
oedema  of  the  structures  around  the  glottis,  foreign  bodies  in 
the  larynx,  wounds  and  fractures  of  the  larynx. 

Acute  Lar3aigitis. — Laryngeal  stenosis  due  to  simple  inflam- 
mation is  rarely  met  with  and  then  it  is  chiefly  dependent 
upon  an  associated  oedema  of  the  structures  around  the 
glottis. 

bleeding,  which  came  from  the  median  jugular  vein,  this  having  been  incised  longi- 
tudinally, I  palpated  the  cervical  tumor  and  the  trachea,  and  to  my  surprise  found 
that  the  latter  was  neither  displaced  nor  compressed  by  the  neoplasm.  I  rapidly 
asked  for  the  previous  history  of  the  patient  and  was  told  that  she  had  for  some  time 
been  treated  by  her  family  physician  for  a  mediastinal  tumor ;  upon  percussion  I 
found  extensive  dulness  over  the  entire  anterior  mediastinum  and  over  the  upper  lobe 
of  the  left  lung.  The  cervical  tumor  represented  a  bunch  of  enlarged  glands  ;  it  played 
no  part  in  the  causation  of  the  dyspnoea.  This  latter  was  due  to  compression  of  the 
bronchi  at  the  root  of  the  lungs  by  the  mediastinal  tumor.  I  at  once  informed  the 
house  surgeon  that  tracheotomy  would  not  relieve  the  patient  unless  it  was  possible 
to  pass  a  stiif  drainage  tube  through  the  tracheal  opening  down  past  the  site  of 
obstruction.  Though  this  was  successfully  accomplished,  the  patient  nevertheless 
succumbed  within  a  fevv  hours.  I  quote  this  history  for  three  reasons  :  first,  to 
show  the  utter  Impossibility  of  relieving  dyspnoea  from  bronchial  obstruction  by  a 
tracheotomy,  unless  such  obstruction  be  due  to  a  foreign  body  ;  second,  to  illustrate 
the  great  importance  of  a  careful  examination  and  a  good  history  in  establishing 
a  diagnosis  ;  and  third,  to  demonstrate  that  in  great  urgency  one  should  never  try 
to  do  a  low  tracheotomy,  for  its  performance  requires  careful  and  accurate  dissec- 
tion, which  is  necessarily  time-consuming,  whereas  a  high  tracheotomy  can  be  rapidly 
and  safely  done  with  a  few  strokes  of  the  knife. 

11 


162     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

The  mild  severity  of  the  constitutional  symptoms,  the 
absence  of  patches  of  false  membrane  in  the  nasopharynx 
or  on  the  tonsils,  and  of  enlarged  cervical  glands,  will  serve 
to  differentiate  this  form  of  laryngeal  obstruction  from  that 
due  to  membranous  croup. 

Diphtheritic  Croup. — Laryngeal  stenosis  due  to  membranous 
croup  is  met  with  chiefly  in  young  children,  whose  laryngeal 
aperture  is  small  and  consequently  more  easily  occluded  than 
that  of  adults.  Except  in  the  cases  of  primary  laryngeal 
diphtheria,  patches  of  false  membrane  are  also  present  in 
the  nasooharvnx  and  on  the  tonsils;  the  cervical  nodes  are 
enlarged;  the  temperature  is  high  and  the  patient  is  usually 
sick  a  number  of  days  before  the  membrane  accumulates 
sufficiently  to  occlude  the  glottis.  It  is  to  be  remembered 
that  in  some  instances  severe  laryngeal  dyspnoea  from  laryn- 
geal croup  may  be  met  with  in  children  who  have  been  well 
up  to  the  onset  of  the  attack.  In  these  cases  it  is  not  the 
membrane  that  occludes  the  larynx,  but  the  catarrhal  swell- 
ing. Such  dyspnoea  is  rarely  severe  enough  to  urgently 
require  tracheotomy  or  intubation.  It  is  relieved  by  an  emetic, 
but  as  the  false  membrane  accumulates  it  again  becomes 
severe.  In  these  cases  the  initial  attack  may  be  taken  for  a 
seizure  of  spasmodic  croup. 

Laryngismus  Stridulus. — Laryngismus  stridulus  occurs  in 
rickety  children;  the  dyspnoea  it  occasions  is  marked,  but 
there  is  neither  laryngeal  cough  nor  hoarseness,  both  of 
which  are  so  characteristic  of  laryngeal  croup. 

Spasmodic  Croup. — Spasmodic  croup  of  young  children 
comes  on,  as  a  rule,  in  the  middle  of  the  night.  The  pre- 
viously healthy  child  wakes  up  out  of  a  sound  sleep  with  a 
croupy  cough,  some  hoarseness  and  dyspnoea,  which  for  a 
time  seems  serious.  The  attack  passes  off  abruptly,  the 
child  falling  asleep  and  the  next  morning  on  awakening  the 
patient  feels  perfectly  well.  Such  a  condition  is  differentiated 
from  diphtheritic  croup  by  the  previous  healthy  condition  of 
the  patient,  the  absence  of  membrane  or  swelling  in  the  naso- 
pharynx or  tonsils,  the  absence  of  temperature  elevations 
and  the  history  of  previous  attacks  of  a  similar  spasm. 

(Edema  of  Structures  of  Glottis. — ffidema  of  the  structures 
which  form  the  glottis  occasions  a  rapidly  increasing  dyspnoea 


DISEASES  OF   THE  LARYNX  163 

usually  without  stridor,  but  the  voice  becomes  husky  and 
disappears.  Laryngoscopic  examination  shows  the  ary- 
epiglottic  folds  and  epiglottis  enormously  swollen  and  dis- 
tended into  fluid  sacs.  Such  an  oedema  is  met  with  as  a 
sequence  to  acute  laryngitis,  diphtheritic  croup,  severe  para- 
laryngeal  inflammations,  as  angina  ludovici,  chronic  laryngeal 
ulcerations  from  tuberculosis  or  syphilis ;  the  acute  infectious 
diseases,  as  scarlet  fever,  typhus  and  typhoid,  and  to  Bright's 
disease.  A  carefully  taken  previous  history  and  a  careful 
physical  examination  of  the  patient,  his  urine,  etc.,  will  usually 
explain  a  sudden  rapidly  increasing  dyspnoea  and  indicate  the 
proper  therapeutic  procedure  that  is  to  be  employed. 

Foreign  Bodies  in  the  Larynx  and  Bronchi. — Foreign  bodies 
in  the  air  passages  may  lodge  in  the  larynx  above  the  vocal 
cords,  or  in  the  rima  glottidis ;  or  they  may  bob  up  and  down 
in  the  trachea,  closing  the  air  tubes  and  glottis  like  a  ball 
valve ;  or  they  may  become  impacted  in  the  bronchi.  Foreign 
bodies  may  further  lodge  in  the  pharynx  just  opposite  to  the 
superior  aperture  of  the  larynx,  and  either  compress  or 
entirely  occlude  the  latter. 

Foreign  bodies  lodging  in  the  larynx  occasion  inspiratory 
or  expiratory  dyspnoea  or  both,  rarely  stridor  or  laryngeal 
cough,  and  hoarseness  only  if  the  body  lies  upon  or  between 
the  vocal  cords.  The  degree  of  dyspnoea  depends  entirely 
on  the  size  and  the  site  of  lodgement  of  the  foreign  body. 
The  diagnosis  is  usually  made  from  the  history.  Imme- 
diately on  being  summoned  to  such  a  case,  the  physician 
should  carefully  palpate  and  search  in  the  pharynx  or  superior 
laryngeal  aperture  to  ascertain  whether  a  foreign  body  is 
lodged  therein.  If  none  is  found  and  the  dyspnoea  is  great, 
immediate  tracheotomy  should  be  made. 

Foreign  bodies  in  the  trachea  occasion  attacks  of  severe 
spasmodic  dyspnoea  which  recur  from  time  to  time  as  the 
result  of  a  cough ;  there  is  also  a  feeling  of  something  moving 
up  and  down  in  the  trachea.  By  auscultation  over  the  trachea 
the  foreign  body  may  be  heard  moving  up  and  down  the 
trachea  with  respiration.  The  spasmodic  attacks  of  dyspnoea 
are  excited  by  the  impact  of  the  foreign  body  against  the 
vocal  cords.  Where  the  case  permits  of  delay,  an  rc-ray 
picture  will  positively  reveal  the  presence  of  the  foreign 


164     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

body;  in  urgent  cases  immediate  tracheotomy  relieves  the 
dyspnoea  and  movable  bodies  will  very  likely  be  expelled 
through  the  tracheal  opening  on  forced  expiration. 

Foreign  bodies  in   the  bronchi   are  usually  impacted  in 
one  or  the  other  of  the  main  or  primary  bronchial  tubes. 

Fig.  90 


Bean  in  right  bronclius.    (Furbinger.) 


When  this  is  the  case  the  corresponding  side  of  the  chest 
does  not  move  with  respiration,  and  there  is  an  absence  of 
vesicular  murmur  over  the  corresponding  lung,  or  a  loud 
sibilant  rale  is  to  be  heard  on  this  side  of  the  thorax,  with 
greatest  intensity  at  the  root  of  the  lungs.     There  may  be 


DISEASES  OF  THE  LARYNX  165 

no  dyspnoea  while  the  patient  is  quiet.  An  absence  of  normal 
breathing  sounds,  or  a  loud  sibilant  rale  over  a  part  of  the 
lung,  points  to  the  lodgement  of  the  foreign  body  in  one  of 
the  smaller  bronchi. 

It  is  to  be  noted  that  small  foreign  bodies  lodging  in  the 
smaller  bronchi  may  occasion  few  if  any  primary  symptoms, 
and  only  after  the  formation  of  a  pulmonary  abscess  or 
bronchiectasis  or  a  localized  consolidation  is  attention  drawn 
to  the  affected  part.  The  anamnesis  may  at  once  reveal  the 
cause,  for  the  pathological  changes  and  the  presence  and  site 
of  the  foreign  body  may  sometimes  be  accurately  determined 
by  the  Roentgen  ray. 

Wounds  and  Fractures  of  the  Larjmx. — In  these  days  of 
intubation,  wounds  and  fractures  of  the  larynx  are  com- 
paratively frequent  from  inexpert  use  of  the  O'Dwyer 
apparatus.  The  diagnosis  is  readily  made.  The  injury  may 
be  inflicted  during  intubation  or  extubation,  more  frequently 
the  latter,  and  is  at  once  followed  by  an  increased  or  renewed 
dyspnoea,  hemorrhage,  and  sometimes  by  emphysema  of  the 
neck. 


CHRONIC  LARYNGEAL  DISEASES. 

Changes  of  the  voice  and  pain  are  the  first  indications  of 
the  chronic  diseases  of  the  larynx;  the  pain  is  referred  to  the 
diseased  part,  radiates  to  the  ears,  and  is  increased  on  swallow- 
ing. Impairment  in  breathing  is  a  later  symptom,  though 
it  is  to  be  remembered  that  sudden  dyspnoea  from  oedema  of 
the  structures  around  the  glottis  is  a  possible  and  ever-threat- 
ening complication  of  these  chronic  laryngeal  affections. 

Changes  in  the  voice,  with  or  without  pain,  or  impaired 
respiration  should  lead  the  attendant  to  make  a  laryngoscopic 
examination. 

The  pictures  to  be  seen  in  the  most  common  of  the  chronic 
diseases  of  this  organ  are  as  follows: 

Chronic  Laryngitis. — In  chronic  laryngitis  the  mucous 
membrane,  especially  the  posterior  part,  is  red,  swollen  and 
thickened;  sometimes  there  are  superficial  ulceration  and 
desquamation;  there  is  also  an  impaired  motility  of  the  vocal 


166     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

cords  from  swelling  and  thickening  of  the  mucous  mem- 
brane. 

Tuberculous  Laryngitis. — In  the  preulcerative  stage,  the 
mucous  membrane  is  swollen  and  rather  nodular,  but  not  dis- 
colored ;  if  the  membrane  is  reddened  it  is  unevenly  so.  The 
ulcerations  usually  commence  posteriorly  and  extend  thence 
around  the  larynx;  they  are  ragged,  worm-eaten  and  sloughy, 
are  surrounded  by  pale,  swollen  mucous  membrane,  and 
show  no  tendency  to  heal;  hence  there  are  no  scars.  In  the 
ulcerative  stage  the  pain  is  marked,  especially  in  swallowing. 

The  general  condition  and  history  of  the  patient  are  of 
great  importance  in  the  diagnosis.  The  existence  of  other 
tuberculous  lesions, especially  in  the  lungs,  should  be  carefully 
sought  for,  and  the  sputum  or  scrapings  from  the  ulcer 
should  be  examined  for  tubercle  bacilli. 

Syphilitic  Laryngitis. — In  syphilitic  laryngitis  the  picture 
as  seen  with  the  mirror  varies.  In  the  secondary  stages  of 
the  disease,  the  whole  or  only  parts  of  the  mucous  membrane 
may  show  a  uniform  or  mottled  congestion,  or  superficial, 
shallow,  irregularly  rounded  ulcers  surrounded  by  an  inflam- 
matory areola,  the  floor  of  which  is  covered  by  a  yellowish 
material.  These  ulcers  heal  and  new  ones  form,  the  healed 
ulcers  being  represented  by  stellate  scars.  In  rare  instances 
mucous  patches  are  seen  on  the  epiglottis,  arytenoids,  and 
vocal  cords.  They  have  a  regular  rounded  outline,  slightly 
elevated  margins,  and  are  surrounded  by  an  inflammatory 
areola,  their  base  being  covered  by  whitish  exudate. 

In  the  tertiary  stages  gummata  are  met  with.  They  are 
located  usually  upon  the  epiglottis  or  arytenoids,  are  single 
or  multiple,  and  form  smooth,  rounded  nodules,  varying  in 
size  from  a  pin's  head  to  a  small  marble.  They  appear 
suddenly,  grow  slowly,  and  undergo  softening  and  ulceration. 
The  defect  thus  created  is  deep,  has  ragged,  sharply  defined 
edges,  surrounded  by  a  deeply  inflamed,  elevated  areola,  and 
the  base  is  covered  by  a  foul  greenish  or  yellowish  necrotic 
tissue.  If  healing  occurs,  stenosis  and  deformities  result  from 
the  contraction  of  the  irregular  scars.  In  establishing  the 
diagnosis,  it  is  of  considerable  aid  to  elicit  a  history  of  syphilis, 
and  to  find  other  evidences  of  syphilis  in  the  bones,  on  the 
skin  and  mucous  membrane,  etc. 


DISEASES  OF   THE  LARYNX 


1G7 


Neoplasms.— With  neoplasms  the  local  manifestations  de- 
pend upon  the  character  and  stage  of  growth  of  the  tumor. 

Papillomata  are  usually  multiple,  prominent,  grayish-white 
growths,  with  irregular  surface,  but  not  ulcerated,  and  have 
little  tendency  to  bleed.  They  may  be  located  above,  upon, 
or  below  the  vocal  cords.     If  the  growth  is  above  the  cords 


Fig.  91 


Multiple  papillomata  of  larynx.    (Von  Bergmann.) 


the  dyspnoea  will  be  chiefly  on  inspiration;  if  below,  chiefly 
on  expiration. 

Fibromata  are  usually  smooth  and  vascular  single  tumors; 
they  sometimes  ulcerate  and  grow  very  slowly. 

Sarcoma  and  carcinoma  form  rapidly  growing  tumors 
which  infiltrate  the  neighboring  parts,  undergo  early  ulcer- 


168     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 

ation,  and  markedly  interfere  with  respiration  and  deglutition. 
The  pain  in  carcinoma  is  very  marked  and  radiates  to  the 
ears;  it  is  less  severe  in  sarcoma.  In  carcinoma  more  fre- 
quently than  in  sarcoma  the  glands  along  the  carotid  are 
enlarged  and  hard  and  fixed.  In  all  doubtful  tumors,  a 
specimen  should  be  excised  and  submitted  to  a  competent 
pathologist  for  examination. 

Fig.  92 


^> 


^^' 


Perichondritis  cricoideus  with  external  abscesses.    (Tiircli.) 


The  other  laryngeal  neoplasms,  such  as  lipoma,  polypi, 
chondroma,  dermoid  and  retention  cysts,  are  more  rarely 
encountered,  and  their  diagnosis  is  readily  made. 

Chronic  Pachydermatous  Laryngitis. — ^A  form  of  chronic 
pachydermatous  laryngitis  is  quite  frequently  met  with.  The 
laryngeal  mucous  membrane  is  thickened,  roughened,  and 
whitish  in  color;  ulceration  is  rare.  This  condition  lasts  a 
long  time,  and  in  many  instances  finally  degenerates  into 
epithelioma. 


DISEASES  OF   THE  LARYNX  169 

Chondritis. — Syphilis,  tuberculosis,  malignant  disease, 
typhoid  fever  and  rheumatism  frequently  invade  the  cartilages 
of  the  larynx,  either  primarily  or  secondarily  to  an  intra- 
laryngeal  lesion,  and  give  rise  to  chondritis  and  perichon- 
dritis, the  latter  being  sometimes  of  a  purulent  character.  The 
diagnosis  is  made  from  the  previous  history  and  the  evidences 
afforded  by  other  foci  of  the  disease.  In  syphilis  there  is 
more  likely  to  be  an  external  swelling  than  in  tuberculosis, 
and  the  syphilitic  affections  show  a  tendency  to  heal.  The 
ulcerations  that  result  from  tuberculosis  are  ragged  and 
worm-eaten  and  are  surrounded  by  protuberant  granulations. 
In  typhoid  fever  the  mucous  membrane  of  the  larynx  is  red, 
boggy,  and  oedematous,  and  if  the  perichondrium  is  invaded  a 
smooth,  tender  swelling  becomes  visible  either  externally  or 
internally.  There  may  be  associated  with  these  lesions  con- 
siderable pain  and  dysphagia,  and  the  patients  may  suffer 
from  attacks  of  severe  dyspnoea.  The  presence  of  gouty  nodes 
in  the  cartilaginous  structures  of  other  parts,  especially  of 
the  ear  and  of  the  finger-joints,  indicates  the  character  of 
firm  nodes  in  the  laryngeal  cartilages. 


CICATRICIAL  STRICTURES. 

Cicatricial  strictures  of  the  larynx  and  trachea  occasion 
permanent  hoarseness  and  dyspnoea,  the  severity  of  which 
depends  on  the  degree  of  stenosis  which  is  present.  Such 
cicatrices  result  from  injuries  and  wounds  of  the  larynx  or 
trachea  inflicted  with  suicidal  intent,  or  from  rough  and 
inexpert  intralaryngeal  or  intratracheal  manipulations  or 
instrumentation,  from  pressure  ulcers  caused  by  the  O'Dwyer 
tubes,  and  especially  by  the  vicious  modifications  of  this 
instrument,  from  syphilitic  ulcerations,  and  from  cicatrization 
of  ulcers  due  to  the  inhalation  or  application  of  irritating 
chemicals.  With  the  mirror  the  adventitious  tissue  is  readily 
seen  and  the  diagnosis  is  easily  established.  The  causation 
of  the  stricture,  which  has  important  bearing  upon  its  treat- 
ment, must  be  ascertained  from  the  history  and  from  the 
physical  examination  of  the  rest  of  the  body. 


170     INJURIES  AND  DISEASES  OF  HEAD  AND  NECK 


IMPAIRED  RESPIRATION. 

Impaired  respiration  and  even  severe  dyspncea  are  not 
infrequently  due  to  compression  of  the  larynx,  trachea,  and 
bronchi  by  neighboring  tumors  or  to  encroachment  upon 
the  superior  laryngeal  aperture  by  tumors,  foreign  bodies  or 
abscesses  in  the  pharynx.  The  diagnosis  of  such  conditions 
is,  as  a  rule,  readily  made  by  palpation,  oropharyngeal 
inspection,  and  laryngoscopic  examination.  Especially  sig- 
nificant and  of  serious  import,  on  account  of  the  danger  of 
urgent  dyspnoea,  are  those  cases  in  which  the  neoplasm  has 
eroded  and  thus  caused  a  pathological  fracture  of  the 
laryngeal  cartilages  or  tracheal  rings.  The  sudden  collapse 
of  the  laryngeal  or  tracheal  walls  at  the  points  of  fracture 
occasions  such  sudden  severe  dyspnoea  that  death  results 
unless  relief  by  tracheotomy  is  immediately  afforded. 


PART   III. 
INJURIES  AND  DISEASES  OF  THE  THORAX. 


CHAPTERXIL 
INJURIES  OF  THE  THORAX. 

The  chief  significance  of  injuries  of  the  thorax  Hes  in  the 
lesions  the  traumatism  inflicts  upon  the  contained  viscera. 
Open  penetrating  wounds  differ  from  subcutaneous  ones  in 
their  greater  likehhood  to  visceral  complications,  in  their 
almost  invariably  resulting  in  pneumothorax,  and  in  their 
liability  to  infection.  However,  it  must  not  be  forgotten  that 
pneumothorax  may  likewise  follow  subcutaneous  rupture  of 
the  lung,  and,  further,  that  subcutaneous  wounds  may  become 
infected  either  through  their  communication  with  the  air 
tubes  or  through  the  medium  of  the  blood.  It  is  natural  to 
expect  a  visceral  complication  to  an  open  penetrating  wound, 
but  it  must  also  be  remembered  that  serious  visceral  lesions 
may  attend  subcutaneous  injuries,  even  when  the  external 
manifestations  are  very  slight.  The  main  point  to  keep  in 
view  is  that  every  patient  who  has  sustained  a  thoracic  injury 
should  be  carefully  examined  for  signs  of  complicating  visceral 
lesions,  as  well  as  for  the  more  striking  and  manifest  external 
ones. 

Commotio  Thoracis. — ^Thoracic  injuries  usually  give  rise  to 
shock,  which  is  proportionate  in  degree  to  the  severity  of  the 
injury.  In  certain  rare  instances,  however,  comparatively 
slight  injuries  have  caused  alarming  and  even  fatal  collapse. 
In  such  cases  the  trauma  has  usually  been  inflicted  over  the 


172      INJURIES  AND  DISEASES  OF   THE   THORAX 

anterior  sternal  region.  The  individual  at  once  falls  over, 
becomes  pale  and  cold,  with  small,  thready,  slow,  irregular 
pulse  and  superficial,  rapid,  and  irregular  respirations.  Most 
of  the  patients  recover  rapidly,  some  more  slowly,  and  a 
few  succumb.  The  symptoms  have  been  ascribed  to  an 
irritation  of  the  vagus  and  cardiodepressor  nerves,  and  the 
condition  has  been  termed  commotio  thoracis.  Such  a  diag- 
nosis is  only  to  be  made  after  a  careful  examination  has 
excluded  an  injury  of  the  visceral  organs.  Severe  or  con- 
tinued hemorrhage  from  wounds  of  the  heart  or  vessels  or 
lungs  naturally  increases  and  prolongs  the  shock  resulting 
from  the  immediate  injury,  and  where  reaction  therefrom 
is  delayed  the  suspicion  of  a  visceral  complication  should 
always  be  entertained. 


INJURIES  OF  THE  THORACIC   WALL. 

Injuries  inflicted  upon  the  thoracic  wall  may  occasion 
thereon  an  open  wound,  or  a  subcutaneous  one,  with  fracture 
of  the  ribs  or  sternum,  severing  or  laceration  of  an  intercostal 
or  the  internal  mammary  artery,  or  a  hsematoma. 

Hoematomata  form  soft,  doughy,  tender  swellings  that 
gradually  shrink  and  become  harder  and  finally  disappear. 
They  are  differentiated  from  abscesses  by  the  absence  of 
local  heat,  temperature  elevations,  and  true  fluctuation. 
Abscesses  grow  larger,  whereas  hsematomata  become  smaller 
and  harder.  Exploratory  aspiration  will  positively  decide 
the  diagnosis. 

Fracture  of  the  ribs  is  evidenced  by  distinct  local  pain  on 
pressure,  pain  at  the  injured  spot  on  deep  inspiration  or 
when  pressure  is  made  over  the  anterior  or  posterior  ends  of 
the  rib,  and  pleuritic  friction  sounds.  Abnormal  mobility, 
displacement,  and  crepitus  are  sometimes  present. 

Fractures  of  the  sternum  are  to  be  recognized  by  abnormal 
mobility,  crepitus,  and  displacement  of  the  fragments,  and 
by  the  pain  which  is  provoked  over  the  site  of  the  injury 
when  one  end  of  the  sternum  is  pressed  upon  or  when  the 
head  is  forcibly  extended. 


INJURIES  OF   THE   THORAX  173 

Rupture  of  an  intercostal  artery  or  the  internal  mammary 
artery  is  followed  by  the  formation  of  a  false  aneurysm, 
which  gives  the  usual  signs  of  this  condition,  viz.,  a  com- 
pressible tumor,  over  which  there  is  a  systolic  murmur  and 
a  thrill. 

Subcutaneous  empliysema  may  form  around  non-penetrat- 
ing wounds ;  it  is  always  circumscribed,  does  not  spread,  and 
tends  to  disappear  rapidly. 


INJURIES  OF  THE  LUNGS  AND  PLEURA. 

Wourids  of  the  lungs  and  pleurae  are  recognized  by  the 
following  conditions  and  symptoms: 

1.  Pneumothorax.  This  causes  respiratory  immobility  of 
the  affected  side  of  the  chest;  rapid,  irregular,  labored  respi- 
rations; slow,  irregular,  small  and  thready  pulse;  and  tympan- 
itic resonance  over  the  entire  affected  side  of  the  thorax. 
Such  pneumothorax  is  less  marked  in  penetrating  wounds 
which  involve  the  pleura  alone  than  in  those  which  are 
complicated  by  a  wound  of  the  lung. 

2.  Hcemopneumothorax.  This  occasions  the  same  disturb- 
ances of  the  pulse  and  respiration  as  does  simple  pneumo- 
thorax, but  gives  different  physical  signs,  viz.,  tympanitic 
resonance  over  the  apex  of  the  chest,  with  flatness  at  the 
base,  and  succussion. 

3.  Subcutaneous  emphysema.  This  is  usually  limited  to  the 
cellular  tissues  at  the  site  at  which  the  injury  was  inflicted, 
but  sometimes  extends  to  the  cellular  tissues  of  a  large  part 
of  the  body. 

4.  Hcemoptysis,  of  varying  profuseness  and  duration. 

5.  Irritable  cough,  and 

6.  Dyspnoea.  This  is  usually  dependent  upon  the  ha^mo- 
pneumothorax,  in  which  case  it  appears  immediately  upon 
reception  of  the  injury;  sometimes  it  is  due  to  an  accumulat- 
ing exudate  within  the  thorax  with  resultant  compression  of 
the  lung,  and  in  this  instance  it  is  first  manifested  several 
days  after  the  injury. 

Pneumothorax  or  heemopneumothorax  may  result  from 
a  penetrating  wound  involving  the  pleura  alone,  or  from  a 


174      INJURIES  AND  DISEASES  OF   THE   THORAX 

penetrating  wound  involving  lung  and  pleura,  or  from  a 
rupture  of  the  lung. 

Subcutaneous  emphysema  may  be  present  in  simple  non- 
penetrating wounds  of  the  chest,  but  it  is  usually  due  to  a 
complicating  wound  or  to  a  rupture  of  the  pleura  and  lung. 
With  non-penetrating  wounds  it  is  always  of  very  limited 
extent,  is  confined  chiefly  to  the  margins  of  the  wound,  and 
therefore  cannot  be  confounded  with  the  more  extensive 
emphysema  that  goes  with  pleural  or  lung  injuries. 

If,  with  a  penetrating  wound,  there  is  present  only  pneumo- 
thorax, or  only  a  very  slight  hsemopneumothorax,  and  no 
haemoptysis,  and  if  the  pneumothorax  rapidly  disappears 
upon  closure  of  the  outer  wound  by  an  abundant  gauze 
dressing,  the  lung  has  in  all  probability  not  been  injured. 
But  if  the  pneumothorax  constantly  increases,  as  evidenced 
by  increasing  dyspnoea  and  higher-pitched  tympanitic  note 
over  the  chest,  or  if  there  is  much  blood  in  the  pleural  cavity, 
and  if  there  is  haemoptysis,  the  likelihood  of  pulmonary 
injury  being  present  is  very  strong.  It  is  to  be  noted 
that  very  considerable  haemopneumothorax  may  result  from 
wounds  of  the  pleura  alone,  the  blood  coming  from  an  injured 
intercostal  or  internal  mammary  vessel;  and,  further,  that 
although  haemoptysis  usually  follows  a  pulmonary  injury,  yet 
small  wounds  of  the  lung  which  are  not  in  communication 
with  a  bronchus,  may  not  be  attended  by  this  symptom;  and 
again,  that  should  the  pleural  layers  have  been  adherent  at 
the  site  over  which  the  injury  was  inflicted,  neither  pneumo- 
thorax nor  haemopneumothorax  would  result. 


INJURIES  OF  HEART  AND  PERICARDIUM. 

Wounds  of  the  heart  and  pericardium  are  in  the  vast 
majority  of  instances  due  to  penetrating  injuries,  the  site  of 
which  over  the  cardiac  area  offers  a  hint  to  the  possibility 
of  involvement  of  these  viscera.  Though  wounds  of  the  peri- 
cardium alone  are  of  infrequent  occurrence,  clinical  evidences 
have  nevertheless  shown  that  this  structure  may  be  injured 
independently  of  the  heart.  As  the  left  pleura  and  lung 
almost  cover  that  portion  of  the  heart  and  pericardium  which 


INJURIES  OF   THE   THORAX  175 

is  not  protected  by  the  sternum,  penetrating  wounds  of  these 
latter  viscera  are  usually  complicatecl  by  wounds  of  the 
former. 

Wounds  of  the  heart  and  pericardium  are  attended  by  one 
invariable  symptom,  viz.,  an  effusion  of  blood  into  the  peri- 
cardial sac.  With  wounds  of  the  pericardium  alone,  and 
with  non-penetrating  wounds  of  the  cardiac  muscle,  the 
heemopericardium  may  be  very  slight,  but  with  penetrating 
wounds  of  the  latter,  and  sometimes  with  wounds  of  the 
pericardium  alone,  it  is  very  great.  Small  amounts  of  blood 
in  the  pericardial  sac  occasion  few,  if  any,  disturbances;  its 
presence  may  never  be  noticed  or  it  is  only  detected  from  the 
pericardial  friction  sounds  which  it  gives  rise  to.  Large 
amounts  of  blood  in  the  pericardial  sac  occasion  the  most 
severe  and  urgent  manifestations,  viz.,  marked  dyspnoea, 
cyanosis,  and  rapid,  irregular,  intermittent  pulse;  on  physical 
examination  the  apex  beat  cannot  be  felt,  there  is  an  increased 
area  of  cardiac  dulness,  and  faintness  or  entire  absence  of 
heart  sounds. 

Hcemopneumopericardium  from  associated  injury  of  the 
lung  and  pleura  is  rare;  it  occasions  a  tympanitic  resonance 
over  the  pericardial  sac  with  succussion,  in  addition  to  the 
other  physical  signs. 

Should  wounds  of  the  lung  and  pleura  complicate  the  injury 
to  the  heart  and  pericardium,  they  would  be  indicated  by 
the  symptoms  which  have  been  detailed  above  (p.  173). 
Pericardial  and  cardiac  injuries  are  likewise  attended  by 
grave  shock. 

It  is,  of  course,  difficult  in  a  given  case,  to  state  definitely 
at  first  sight  whether  a  penetrating  wound  in  the  cardiac  area 
involves  the  pericardium  alone  or  also  the  heart.  Deep 
shock,  great  anxiety,  and  large  degrees  of  hsemopericardium 
point  to  coincident  lesions  of  the  heart,  an  indication  that  is 
made  more  certain  by  a  pulsating  hemorrhage  from  the 
external  wound,  and  by  the  presence  of  blowing,  metallic, 
or  purring  murmurs  over  the  heart.  It  is  not  to  be  forgotten, 
however,  that  even  severe  injuries  of  the  heart  may  be 
attended  by  no  shock  and  little  hsemopericardium,  the  wound 
in  the  viscus  being  temporarily  closed  or  being  not  completely 
penetrating.    On  account  of  the  danger  of  carrying  in  infec- 


176       INJURIES  AND  DISEASES  OF   THE   THORAX 

tion,  probing  of  the  wound  is  not  advisable.  In  cases  of 
doubt  it  is  better  to  freely  expose  the  pericardial  sac  and 
determine  by  direct  sight  and  touch  the  extent  and  character 
of  the  injury. 


INJURIES  OF  LARGE  BLOODVESSELS. 

Injuries  of  the  large  bloodvessels  result  in  such  speedy 
death  from  hemorrhage  that  no  opportunity  for  their  diag- 
nosis is  afforded. 


INJURIES  OF   (ESOPHAGUS. 

Injuries  of  the  oesophagus  are  readily  recognized  by  the 
escape  of  ingesta  and  mucus  through  the  external  wound. 


INJURIES  OF  DIAPHRAGM. 

Injuries  of  the  diaphragm  result  from  penetrating  wounds 
and  from  severe  crushing  violence.  They  are  usually  compli- 
cated by  lesions  of  the  thoracic  and  abdominal  viscera  and 
are  masked  by  the  symptoms  which  the  latter  occasion.  The 
chief  significance  of  tears  and  wounds  of  the  diaphragm  lies 
in  the  possibility  such  injuries  offer  for  the  prolapse  of  one 
or  more  of  the  abdominal  viscera  into  the  thorax.  If  a 
considerable  part  of  the  stomach  and  intestines  are  so  pro- 
lapsed the  heart  is  displaced,  the  lungs  are  compressed, 
there  is  marked  dyspnoea  and  tympanitic  resonance  over  the 
chest,  and  there  is  danger  that  the  prolapsed  bowel  will  be 
constricted  and  strangulated  by  the  opening  in  the  wounded 
midriff  with  resulting  intestinal  obstruction  and  gangrene. 

Uncomplicated  wounds  of  the  diaphragm  usually  pass 
unnoticed.  They  occasion  pain  at  the  site  of  the  lesion,  which 
sometimes  radiates  to  the  shoulder  and  is  especially  marked 
on  forced  respiration  or  cough.  Visceral  prolapse  should  be 
strongly  suspected  when  there  is  dyspnoea,  tympanitic 
resonance  over  the  lower  thoracic  area,  and  displacement  of 


INJURIES  OF   THE   THORAX  177 

the  heart,  and  especially  if  there  is  intestinal  obstruction  and 
vomiting.  It  should  be  remembered,  however,  that  a  thoracic 
injury,  followed  by  a  diaphragmatic  pleurisy,  sometimes 
occasions  intense  abdominal  pain,  constipation  and  vomiting, 
and  so  resembles  the  cases  of  diaphragmatic  injury  in  which 
visceral  complications  are  present. 

The  difficulty  of  differentiating  the  two  conditions  is 
especially  great  when  only  a  single  knuckle  of  intestine  or 
small  section  of  the  stomach  is  prolapsed  into  the  thorax 
and  strangulated,  and  when  there  is  consec[uently  an  absence 
of  dyspnoea,  tympanitic  resonance,  and  displaced  heart. 
With  pleurisy,  however,  the  constipation  is  never  absolute, 
nor  the  vomiting  persistent,  as  is  the  case  with  strangulation 
and  obstruction  of  the  bowel. 


12 


CHAPTER  XIII. 

INFLAMMATIONS  AND  NEOPLASMS  OF  THE  CHEST 

WALL. 

ABSCESSES  OF  THE  THORACIC  WALL. 

Acute  Suppuration. — Acute  suppuration  of  the  thoracic 
wall  affords  the  signs  that  attend  such  a  condition  in  other 
parts — ^viz.,  local  pain,  heat,  temperature  elevation,  and 
increased  leukocytosis.  If  the  abscess  is  superficially  located, 
fluctuation  appears  early;  otherwise  this  is  not  palpable  at 
all  or  only  after  the  abscess  has  come  nearer  to  the  surface. 
Superficial  abscesses  become  more  prominent  when  the  under- 
lying muscles  are  contracted,  whereas  deeply  seated  ones 
become  flatter  and  less  prominent  when  the  muscles  are  put 
on  the  stretch.  In  doubtful  cases  aspiration  will  decide 
whether  pus  is  present. 

Mural  abscesses  secondary  to  pulmonary  abscesses  usually 
contain  gas.  When  they  do,  they  are  tympanitic  to  percussion 
and  therein  resemble  hernise  of  the  lung.  The  differentiation 
is,  howev^er,  readily  made;  for  hernise  of  the  lung  can  be  easily 
replacied  into  the  chest,  which  abscesses  cannot  be,  and  they 
do  not  present  the  usual  signs  of  inflammation. 

With  mural  abscesses  secondary  to  empyema  there  will  be, 
in  addition  to  the  above  signs,  those  characteristic  of  empyema 
and  aspiration  of  the  pleural  cavity  will  yield  pus. 

Deeply  seated  abscesses  and  phlegmons  of  the  chest  wall 
may  at  their  incipiency  be  confounded  with  intrathoracic 
lesions,  pleurisy,  and  pneumonia,  but  the  subsequent  develop- 
ment of  the  physical  signs  which  attend  the  latter  maladies 
will  serve  to  differentiate  them. 

Chronic  Suirsurations. — Chronic  suppurations  of  the 
thoracic  wall  are  usually  secondary  to  tuberculous  disease 
of  its  bony  structures;  more  rarely  they  are  actinomycotic 
or  syphilitic,  and  sometimes  they  are  due  to  an  extension 


INFLAMMATIONS  OF   THE  CHEST  WALL  179 

of  a  suppuration  from  glandular  abscesses  in  the  axilla. 
They  form  soft,  fluctuating,  slowly  growing,  painless  swell- 
ings that  are  made  more  prominent  by  muscular  contraction 
if  they  are  superficial,  and  less  so  if  they  are  deeply  placed. 
Their  tendency  is  to  burrow  along  the  muscular  planes, 
perforate  the  latter,  and  eventually  break  through  the  skin 
in  one  or  more   places,   thus   creating  profusely   secreting 

Fig.  93 


Mural  thoracic  abscess  from  perforation  ot  empyema.    Note  enlargement  of  the 
right  side  of  chest,  suggesting  large  pleural  exudate. 

sinuses,  whose  external  opening  bears  testimony,  both  by  its 
appearance  and  by  the  character  of  its  discharge  as  to  the 
nature  of  the  underlying  malady.  Thus,  retracted,  irregular 
scars  and  fistulous  openings,  from  which  a  cheesy,  flocculent 
material  is  discharged,  are  very  suggestive  of  tuberculosis; 
a  great  deal  of  brawny  induration  surrounding  small  areas 
of  softening  and  a  discharge  of  minute  yellowish  granules 


180      INJURIES  AND  DISEASES  OF   THE   THORAX 

containing  the  ray  fungus  are  indicative  of  actinomycosis; 
and  a  discharge  of  a  homogeneous  stringy  material  suggests 
syphihs.  Other  evidences  of  syphilis  or  tuberculosis  will 
help  to  substantiate  the  diagnosis. 

The  tortuosity  of  the  channels  along  which  the  pus  has 
burrowed  often  makes  it  difficult  to  locate  the  site  of  the 
primary  affection.  This  is  best  done  by  withdrawing  the 
contents  of  the  abscess  cavity  with  an  aspirating  needle  and 

Fig.  94 


Tuberculosis  of  the  ribs  and  sternum.    Note  the  retracted,  irregular  scars  and  the 
multiple  fistulEe.    (Von  Bergmann.) 

then  injecting  into  it,  under  considerable  pressure,  some 
10  per  cent,  solution  of  iodoform  glycerin.  The  latter  makes 
its  way  along  the  tortuous  channels,  and  on  exposing  the 
patient  to  the  a;-ray,  the  entire  course  of  the  abscess  down  to 
its  primary  site  is  easily  followed. 

Aneurysms  of  the  large  intrathoracic  vessels  or  of  the 
intercostal  or  mammary  arteries  are  differentiated  from 
chronic  abscesses  by  their  compressibility,  their  expansile 


INFLAMMATIONS  OF   THE  CHEST   WALL 


181 


pulsation,  the  systolic  murmur  and  bruit  to  be  heard  over 
them,  and  the  intense  boring  pain  to  which  they  give  rise. 

Hernise  of  the  lung,  in  contradistinction  to  chronic 
abscesses,  are  tympanitic  to  percussion  and  can  be  easily 
replaced  within  the  chest. 


Fig.  95 


Large  cold  abscess  of  the  thorax,  from  syphilitic  disease  ot  the  ribs.   Note  the  absence 
of  tuberculous  lesions  in  other  organs.    (Von  Bergmann.) 


NEOPLASMS  OF  THE  CHEST  WALL. 


Benign  neoplasms  offer  little  difficulty  in  their  diagnosis. 
Atheromata,  dermoids,  and  lipomata  occur  most  frequently 
on  the  back  as  soft  elastic  tumors,  having  pseudofluctuation. 
They  may  be  confounded  with  chronic  abscesses;  the  latter. 


182      INJURIES  AND  DISEASES  OF   THE   THORAX 

however,  are  of  more  rapid  growth,  are  distinctly  fluctuating, 
and  are  not  lobulated  nor  attended  with  dimphng  of  the  skin 
as  are  Hpomata.  In  doubtful  eases  aspiration  will  at  once 
clear  up  the  diagnosis.  Retromammary  lipoma  push  forward 
the  breast  and  make  the  impression  of  an  hypertrophied 
gland.  Fibromata  form  hard,  very  slowly  growing,  usually 
submuscular,  and  not  very  movable  tumors,  and  neuro- 
fibromata  form  hard,  very  sensitive  growths  along  the  inter- 

FiG.  96 


Retromammary  lipoma.    (Albert.) 

costal  nerve  trunks  and  provoke  severe  neuralgic  pain.  Of 
vascular  tumors,  the  noevi  and  telangiectatic  growths  are 
readily  recognized  by  their  surface  appearance  and  their 
compressibility.  Enchondromata  occasionally  form  on  the 
ribs  and  sternum,  usually  at  their  junction  with  the  carti- 
lages, constituting  hard,  very  slowly  growing  tumors,  that 
may,  however,  attain  considerable  size  and  give  rise  to 
metastases  in  other  organs. 


CHAPTER  XIV. 
DISEASES  OF  THE  BREAST. 

Clinical  History  and  Method  of  Examination. — In  the 
clinical  history  of  those  suffering  with  affections  of  the 
breasts  it  is  important  to  ascertain  whether  there  has  ever  been 
any  injury  to  the  organ,  whether  the  patient  has  ever  nursed 
and  the  time  of  the  last  nursing,  whether  there  have  been 
previous  inflammatory  conditions  in  the  gland,  and  whether 
there  is   any  evidence  pointing  to  tuberculosis   or  syphilis. 

In  examining  the  breast,  the  physician  should  sit  in  front 
of  the  patient.  He  should  compare  the  size  of  the  two 
glands  and  should  take  note  of  their  surface  appearance, 
the  condition  of  the  nipples  and  their  areola,  and  when 
there  is  a  discharge  from  the  nipple  he  should  mark  its 
amount  and  its  character.  In  palpating  the  organ,  the 
pectoral  muscles  should  be  relaxed  by  raising  and  supporting 
the  corresponding  arm  at  a  level  with  the  shoulder.  The 
whole  gland  should  then  be  rolled  beneath  the  flat  of  the 
hand,  and  any  thickenings,  irregularities  or  neoplastic  forma- 
tions within  it  noted.  The  mobility  of  the  gland  upon  the 
thorax  and  the  mobility  of  its  cutaneous  covering  should  also 
be  determined.  No  examination  is  complete  until  the  axilla 
has  been  carefully  palpated.  This  is  best  done  by  crowding  the 
axillary  contents  against  the  chest  wall,  or  against  the  humerus, 
and  then  palpating  them  with  the  finger  tips.  The  supra- 
clavicular spaces  should  also  be  palpated  for  enlarged  glands. 


INFLAMMATORY  DISEASES  OF  THE  BREAST. 

Acute  Inflammation. — Acute  inflammation  of  the  breast, 
characterized  by  a  painful  swelling  of  the  gland  and  at  times 
by  a  reddening  of  the  skin  over  it,  occurs  with  especial 


184      INJURIES  AND  DISEASES  OF   THE   THORAX 

frequency  in  the  newborn  (in  males  more  frequently  than 
in  females)  and  at  puberty. 

Acute  Suppurative  Mastitis. — Acute  suppurative  mastitis 
is  met  with  most  often  in  women  during  the  lactation  period. 
It  is  characterized  by  the  usual  signs  of  acute  suppuration — 
viz.,  swelling,  redness,  heat,  rise  of  temperature,  and  increased 
leukocyte  count.  The  abscesses  may  be  superficial,  beneath 
the  skin,  or  within  the  substance  of  the  gland,  or  retro- 
mammary. In  the  first  two  instances  fluctuation  appears 
early,  but  in  the  latter  it  is  to  be  obtained  only  very  late  or 
not  at  all.    Some  axillary  glandular  swelling  is  always  present. 

In  a  patient  that  recently  came  under  the  care  of  the 
author,  the  tenderness  and  redness  of  the  skin  overlying  a 
tumor  in  the  breast  and  the  axillary  enlargement  suggested 
to  her  family  physician  an  abscess  formation,  which  he 
proceeded  to  incise.  The  advanced  age  of  the  patient,  the 
hardness  and  immobility  of  the  tumor  and  of  the  axillary 
glands,  with  the  absence  of  constitutional  symptoms,  should 
have  easily  enabled  liim  to  exclude  abscess  and  diagnosticate  a 
malignant  neoplasm,  which  had  become  adherent  to  the  skin 
and  was  about  to  ulcerate  through  it. 

Chronic  Mastitis. — The  chronic  forms  of  mastitis  are 
difficult  of  differentiation  from  neoplastic  formation.  As  a 
result  of  chronic  inflammatory  processes,  multiple  smaller 
and  larger  cysts  form  in  the  breast,  or  isolated  lobules  of  the 
gland,  become  the  seat  of  a  nodular  infiltration,  occasionally 
accompanied  by  axillary  glandular  enlargement  and  atrophy 
and  retraction  of  the  breast.  Such  chronic  mastitis  is  met 
with  after  puberty,  especially  in  women  who  have  borne 
children,  but  not  nursed  them.  It  mav  involve  one  or  both 
breasts.  The  nodules  and  cysts  are  best  appreciated  by 
squeezing  the  breast  between  the  thumb  and  forefinger. 
The  cysts  are  rarely  larger  than  a  w^alnut,  are  tense  and  at 
times  fluctuating,  wdiile  the  nodules  are  firm  and  leather^-. 
Compression  of  the  breast  may  cause  a  few  drops  of  milky 
or  brownish  fluid  to  exude  from  the  nipple. 

The  multiplicity  of  the  tumors,  their  smooth  surface,  the 
fluctuation  of  the  cysts,  the  variations  in  size  and  consistency 
of  the  nodules  (now  hard,  now  soft,  now  large,  now  small), 
the  absence  of  lancinating  pain  in  the  breast  (though  radiat- 


DISEASES  OF   THE  BREAST  185 

ing  pain  to  the  axilla  may  be  complained  of),  the  mobility  of 
the  breast  upon  the  thorax  and  muscles,  and  the  long  duration 
and  slow  progress  of  the  malady,  usually  suffice  to  difFer- 
entiate  these  cases  from  neoplasms.  The  internal  admin- 
istration of  the  iodides  acts  favorably  upon  the  size  and 
consistency  of  the  nodules,  and  they  should  always  be  given 
to  aid  us  in  the  diagnosis.  In  doubtful  cases  an  exploratory 
incision,  with  immediate  examination  of  a  frozen  section 
under  the  microscope,  is  to  be  made.  Under  no  condition 
is  a  patient  wdth  chronic  mastitis  to  be  dismissed  from  our 
observation,  for  malignant  degeneration  may  occur  at  any 
time,  and  the  patient  should  have  the  benefit  of  an  early 
detection  of  such  a  change  in  the  breast. 

Benign  Hypertrophy. — Benign  hypertrophy  of  the  breasts 
may  occur  at  the  time  of  puberty.  It  usually  affects  both 
breasts.  Unilateral  hypertrophy  is  suggestive  of  neoplasm. 
The  breasts  rapidly  become  very  large,  but  remain  soft, 
elastic,  and  movable,  and  do  not  cause  pain. 

Tuberculosis. — Tuberculosis  is  rarely  primary  in  the 
breasts,  though  secondary  infection  from  tuberculosis  of  the 
lungs,  ribs,  sternum,  etc.,  is  fairly  frequent.  It  appears 
either  as  a  circumscribed  cold  abscess  or  more  usually  as 
disseminated  indurated  nodules,  having  an  irregular  surface. 
The  nodules  tend  to  enlarge  slowly,  become  soft  in  their 
centre  and  eventually  perforate,  leaving  fistulse  which  dis- 
charge cheesy,  flocculent  material.  The  axillary  glands 
sooner  or  later  become  enlarged. 

In  the  early  stages  the  nodules  are  chfficult  to  differentiate 
from  cancerous  nodes.  Other  evidences  of  tuberculosis  may 
suggest  the  diagnosis,  but  no  positive  conclusion  can  be 
arrived  at  until  a  microscopic  examination  of  a  section  of 
the  nodule  has  been  made.  Wlien  caseous  degeneration  and 
fistulse  have  formed  the  diagnosis  is  easy. 


NEOPLASMS  OF  THE  BREAST. 

Clinically  w^e  are  chiefly  concerned  as  to  whether  a  neo- 
plasm in  the  breast  is  of  a  benign  or  malign  character. 
Histologically   it   ls   essential   to   differentiate   betw^een   the 


186      INJURIES  AND  DISEASES  OF   THE   THORAX 

various  connective  tissue  and  epithelial  tumors  and  their 
combinations  (the  fibroma,  myxoma,  lipoma,  angioma,  chon- 
droma, atheroma  and  sarcoma  among  the  former,  and  the 
adenoma  and  carcinoma  among  the  latter),  but  clinically 
this  differentiation,  at  least  in  the  initial  stages,  is  often 
impossible.  In  this  organ  especially,  where  early  positive 
diagnosis  of  benignancy  or  malignancy  is  not  always  possible, 
there  is  need  of  frequent  resort  to  exploratory  incision  and 
histological  examination  of  an  excised  specimen  of  the 
growth.  Only  in  this  way  can  we  hope  to  arrive  at  an  early 
positive  diagnosis  in  the  obscure  cases. 

Benign  Tumors. — Benign  tumors  grow  slowly,  and  are 
and  remain  circumscribed,  encapsulated  and  movable.  Of 
tumors  with  these  characteristics  the  most  common  are  the 
fibroadenoma,  which  are  usually  rounded,  smooth  (rarely 
irregularly  lobulated),  firm  tumors  while  small,  with  areas 
of  softer  consistency  when  they  attain  larger  size,  and  with 
fluctuating  areas  when  cysts  develop  in  them.  Lipoma, 
angioma,  and  chondroma  are  rare,  and  are  recognized  by  the 
special  characteristics  of  fatty,  vascular,  and  cartilaginous 
tumors. 

Simple  cystic  tumors,  not  as  parts  of  fibroadenoma, 
sarcoma,  or  carcinoma,  also  occur;  they  are  usually  retention 
cysts,  their  contents  being  serous  or  mucoid  or  oily  or  creamy 
material.  In  the  latter  instance  the  cyst  is  termed  "galacto- 
cele." 

Malignant  Tumors. — Malignant  tumors  are  most  frequent 
after  the  fortieth  year  of  life;  they  are  hard  (in  many  cases 
stony  hard),  grow  rapidly,  either  are  not  or  speedily  lose 
their  encapsulation,  and  very  early  become  adherent  and 
fixed  in  the  breast,  to  the  thorax,  and  to  the  skin.  Carcino- 
mata  are  very  early  attended  with  enlargement  and  indura- 
tion of  the  axillary  glands;  in  sarcoma  the  glandular  enlarge- 
ment appears  late  or  not  at  all.  These  tumors  cause  marked 
interference  with  general  health,  cachexia,  and  are  followed 
sooner  or  later  by  secondary  growths  in  other  organs,  most 
especially  the  lungs,  pleura,  and  vertebrae.  As  the  growth 
enlarges  it  becomes  adherent  to  the  skin,  breaks  through 
it  and  leaves  an  ulcer  which  in  carcinoma  has  everted, 
indurated   edges,  and  a  granulating,  easily  bleeding,  crusty 


DISEASES  OF  THE  BREAST 


187 


base,  and  in  sarcoma  undermined,  indurated  edges  and  a 
fungous  base. 

The  rapidity  of  growth  depends  upon  the  vascularity  of 
the  breast,  and  upon  the  amount  of  fibrous  tissue  in  the 
neoplasm.     Thus,  in  nursing  breasts  the  growth  is  very 


Fig.  97 


Large  ulcerating  sarcoma  of  the  breast.    Note  fungous  character  of  the  ulcer  which 
suggests  the  nature  of  the  tumor. 

rapid,  while  in  an  old  subject  the  progress  is  considerably 
slower;  similarly  the  richly  cellular  tumors  increase  in  size 
very  rapidly,  while  the  fibrous  ones  grow  very  slowly.  The 
presence  of  the  fibrous  tissue  leads  to  retraction  of  the  nipple 
and  the  skin  overlying  the  tumor,  but  the  absence  of  this 
retraction  is  not  an  evidence  of  non-malignancy  any  more 


188      INJURIES  AND  DISEASES  OF   THE   THORAX 

than  its  presence  is  a  proof  of  it.  (With  the  contraction  of 
fibrous  tissue,  no  matter  whether  benign  or  maHgn  in  char- 
acter, retraction  of  the  skin  and  nipple  always  occur.) 

Of  the  malignant  tumors,  we  are  wont  to  differentiate  the 
sarcoma  and  carcinoma.  The  former  are  more  frequent 
between  the  twentieth  and  fortieth  year,  the  latter  after  forty; 
and  with  the  latter  the  axillary  glandular  involvement  appears 
early,  while  in  sarcoma  the  glands  enlarge  late  or  not  at  all. 
Clinically,  however,  it  is  not  always  possible  to  distinguish 
between  them. 

Fig.  9S 


Carciuoma  of  left  breast  in  a  male.    Note  diffuse  enlargement  of  the  gland,  which 
was  hard  and  fixed  to  the  chest;  axillary  lymph  nodes  enlarged. 


Sarcoma. — Of  the  sarcoma  we  may  distinguish  clinically: 

1.  The  cystic  sarcoma,  forming  encapsulated  movable 
tumors  with  irregular  surface  and  of  unequal  consistency, 
with  varying  rapidity  of  growth,  and  attaining  at  times  very 
large  size. 

2.  The  soft  sarcoma  (medullary  and  melanosarcoma), 
which  grow  very  rapidly  and  infiltrate  the  breast. 

3.  The  hard  sarcoma  (fibro-  and  spindle-celled  sarcoma), 
which  grow  slowly  and  infiltrate  the  breast. 


DISEASES  OF   THE  BREAST 


189 


Carcinoma. — Of  the  carcinoma  we  may  distinguish: 

1.  The  acinous  (medullary  carcinoma),  forming  soft 
tumors  which  tend  to  early  degeneration  and  ulceration, 
and  from  the  base  of  which  fungoid  granulations  appear. 

2.  The  tuhnlar  or  simple  carcinoma,  forming  flattened 
tumors  that  infiltrate  the  skin,  muscles,  ribs  and  pleura, 
often  in  a  disconnected  chain  (at  times  there  are  multiple 

Fig.  99 


Carcinoma  of  the  right  breast  in  pregnant  woman.    Its  character  could  only  be 
determined  by  histological  examination  of  a  frozen  section. 


hard  nodules  in  the  skin  of  the  breast,  back,  and  arm  (cancer 
en  cuirasse),  while  the  remaining  skin  is  of  board-like  hard- 
ness and  inflamed). 

3.  The  scirrhous  carcinoma,  of  slow  growth  with  contrac- 
tion and  atrophy  of  parts  of  the  neoplasm;  it  is  met  with 
commonly  in  old  subjects. 

4.  The  colloid  carcinoma,  of  slow  growth  and  affording  the 
best  prognosis  after  removal. 


190       INJURIES  AND  DISEASES  OF  THE   THORAX 

It  is  to  be  especially  noted  that  differentiation  between 
small  sarcoma,  carcinoma,  fibroma,  adenoma,  and  chronic 
mastitis  is  not  always  possible.  Stony  hardness,  non- 
encapsulation,  and  lancinating  pain,  steady  progression  and 
unchanging   character  should   always   excite  suspicions   of 

Fig. 100 


"X 


Atrophic  scirrhous  carcinoma  of  the  breast.    (Von  Bergmann.) 

malignancy  and  prompt  an  early  exploratory  incision  with 
microscopic  examination  of  an  excised  specimen  of  the 
growth.  When  the  axillary  glands  have  become  intumescent 
and  indurated  the  diagnosis  is  easy,  but  the  radical  cure  of 
the  disease  is  usually  out  of  the  question. 


DISEASES  OF   THE  BREAST  191 

Diseases  of  the  Nipple. — The  nipple  and  its  areola  may  be 
the  seat  of  erosions,  syphilitic  condylomata,  atheroma,  and 
epithelial  carcinoma.  Paget's  disease,  falsely  styled  chronic 
eczema  of  the  nipple,  is  an  epithelioma,  which  originates  in 
the  epithelia  surrounding  the  orifices  of  the  ducts.  In  the 
earlier  stages  of  this  affection  the  nipple  is  reddened  and 
painful,  has  a  granulating  appearance,  and  discharges  a 
clear,  yellowish  fluid;  or  a  psoriatic  condition  develops 
around  the  nipple.  The  differentiation  from  chronic  eczema 
or  psoriasis  is  difficult,  but  our  suspicion  should  be  aroused 
if  the  malady  proves  rebellious  to  local  treatment. 


CHAPTER   XV. 

DISEASES  OF  THE  PLEURA  AND  LUNGS. 

This  chapter  will  be  devoted  to  the  diagnosis  of  empyema 
of  the  pleura,  and  abscess,  gangrene,  and  neoplasms  of  the 
lung;  but  for  the  detailed  physical  evidences  of  these  diseases 
the  reader  is  referred  to  books  on  internal  medicine. 

EMPYEMA. 

Empyema  of  the  pleura  is  usually  secondary  to  pulmonary 
inflammation,  less  frequently  to  infradiaphragmatic  suppu- 
ration, or  suppuration  of  the  chest  wall,  rarely  primary 
without  pulmonary  lesion,  exceptionally  a  manifestation  of 
pysemia,  and  sometimes  due  to  an  infected  penetrating 
wound  of  the  chest.  The  pus  may  be  free  in  the  pleural 
cavity,  or  it  may  be  encapsulated;  if  the  encapsulation  is 
between  the  lobes  of  the  lung,  an  interlobar  abscess  is  formed. 
The  free  exudates  are  easier  of  diagnosis  and  differential 
diagnosis  than  are  the  encapsulated  ones. 

It  is  to  be  distinctly  noted  that  although  the  presence  of 
fluid  within  the  pleural  cavity  can  usually  be  diagnosticated 
from  the  physical  signs,  and  its  character  be  probably 
determined  from  the  temperature  curve  and  blood  count 
(high  leukocytosis,  above  20,000,  pointing  to  pus),  yet  the 
only  positive  way  of  ascertaining  the  presence  and  nature 
of  a  pleural  exudate  is  by  aseptic  puncture.  If  this  is  done 
properly,  no  harm  can  result,  and  only  in  rare  instances  of 
encapsulated  exudates  are  negative  results  obtained  when 
pus  or  fluid  is  present  in  the  pleural  cavity.  If  the  first 
puncture  is  negative,  we  should  not  hesitate  to  repeat  the 
procedure  a.  number  of  times  if  the  physical  signs  and 
constitutional  symptoms  point  to  the  presence  of  pus. 


DISEASES  OF  THE  PLEURA   AND  LUNGS 


193 


Physical  Signs. — The  classical  physical  signs  afforded  by 
a  pleural  exudate — viz.,  enlargement  of  the  affected  side  of  the 


Fig.  101 


Topography  of  the  thoracic  a  nd  upper  abdominal  organs.  Note  limits  of  the  pleurae 
and  lungs  in  reference  to  the  bony  chest  wall.  1.  Sternal  end  of  the  clavicle 
2.  Thymus  gland.  3.  Mediastinal  layers  of  the  pleura.  4.  Upper  lobe  of  left  lung. 
5.  Pericardial  layer  of  pleura.  6.  Anterior  mediastinum.  7.  Costophrenic  sinus. 
8.  Left  lobe  of  liver.  9.  Greater  curvature  of  stomach.  10.  Bursa  omentalis.  11.  Trans- 
verse colon.  12.  Great  omentum.  13.  Inferior  omental  recess.  14.  Dome  of  the 
pleura.  15.  Upper  mediastinum.  16.  Right  lung.  17.  Mediastinal  layers  of  the 
pleura.  18.  Right  lung.  19.  Fatty  folds  of  the  pleura.  20.  Diaphragmatic  pleura. 
21.  Diaphragm.  22.  Falciform  ligament  of  the  liver.  23.  Right  lobe  of  liver.  24.  Round 
ligament  of  liver.  25.  Fundus  of  gall-bladder.  26.  Gastrocolic  ligament.  27.  Great 
omentum. 


chest,  diminution  of  its  respiratory  movement,  absence  of  vocal 
fremitus   and  voice,   dulness   on   percussion,   absence   of  or 

13 


194      INJURIES  AND  DISEASES  OF  THE   THORAX 

greatly  diminished  respiratory  murmur,  and  displacement  of 
the  heart,  diaphragm,  and  lung — may  be  somewhat  irregular 
and  resemble  those  which  are  given  by  a  pneumonic  con- 
solidation. If  the  exudate  forms  during  the  existence  of  a 
pneumonia  or  immediately  after  its  defervescence,  the 
physical  signs,  high  fever  and  high  leukocyte  count,  may  be 
attributed  to  delayed  resolution  of  the  pneumonia.    In  these 

Fig. 102 


Enlargement  of  the  left  chest  from  large  pleuritic  exudate.    (Weintraub.) 


cases  especially  is  exploratory  aspiration  to  be  practised,  in 
order  to  make  an  accurate  diagnosis. 

Purulent  collections  below  the  diaphragm  (subphrenic 
abscess)  give  physical  signs  that  are  somewhat  similar  to 
those  afforded  by  empyemata.  But  with  subphrenic  abscess 
there  is  an  elevated,  dome-shaped,  basal  dulness,  with  normal 
pulmonary  resonance  above  it,  and  normal  vesicular  breath- 
ing can  be  heard  up  to  the  level  of  dulness;  whereas  in 
empyema  the  breathing  is  altered  up  to  the  top  of  the  chest, 


DISEASES  OF   THE  PLEURA   AND  LUNGS 


195 


and  the  basal  dulness  is  concave  upward.  The  history  of  a 
preceding  intra-abdominal  suppuration  or  of  visceral  perfo- 
ration is  strongly  suggestive  of  subphrenic  abscess.  In  some 
instances  a  purulent  or  serous  pleural  effusion  develops 
secondarily  to  the  subphrenic  abscess,  and  its  presence  makes 
the  diagnosis  of  the  subphrenic  abscess  more  difficult. 

A  coincident   pleural    and   subphrenic   exudate  is  to  be 
strongly  suspected  when  on  transpleural  aspiration  we  obtain 


Fig.  103 


Anterior  view  of  shape  of  the  upper  line  of  flatness  in  left  pleural  exudate. 

(Weintraub.) 


one  kind  of  pus  from  the  subphrenic  space  and  another  kind 
of  pus  or  a  serous  fluid  from  the  pleural  cavity. 

The  sacculated  pleural  exudates  are  more  difficult  of  diag- 
nosis because  the  classical  physical  signs  are  apt  to  be  some- 
what irregular,  and  especially  difficult  are  the  cases  in  which 
the  pus  is  encapsulated  between  the  lobes  of  the  lung  (the 
interlobar  abscesses).  It  is  in  this  class  of  cases  that  we  have 
the  greatest  use  for  aseptic  exploratory  aspiration,  and  if  the 


196      INJURIES  AND  DISEASES  OF   THE   THORAX 

first  puncture  is  negative  the  procedure  should  be  repeated 
until  the  pus  is  found.  The  interlobar  abscess  usually  points 
between  the  anterior  and  posterior  axillary  lines,  over  the 
course  of  the  incisures  of  the  lung.  An  interlobar  exudate 
is  distinguished  from  a  pulmonary  abscess  which  communi- 
cates with  a  bronchus  by  the  absence  of  elastic  fibres  in  the 
sputum,  the  absence  of  a  profuse  three-layer  sputum,  and  by 


Posterior  view  of  same  as  Fig.  103.    (Weintraub.) 


the  constancy  of  the  physical  signs.  (With  pulmonary 
abscess  the  physical  signs  vary  before  and  after  expectora- 
tion.) From  pulmonary  abscess  not  in  communication  with 
a  bronchus  the  differentiation  is  impossible,  and  may  even 
remain  so  on  the  operating  table. 

Chronic  Sacculated  Empyema. — A  chronic  sacculated 
empyema  may  be  simulated  by  a  chronic  'pneumonia  with 
bronchiectasis,  in  which  the  large  bronchi  and  the  cavities 


DISEASES  OF   THE  PLEURA   AND  LUNGS         197 

are  filled  with  exudate  and  sputum.  Aspiration  may  even 
yield  a  purulent  material  which  is  derived  from  the  cavities. 
An  abrupt  outline  of  the  area  of  dulness  and  the  expecto- 
ration of  large  masses  of  sputum  are  characteristic  of  the 
latter  malady. 

A  chronic  sacculated  empyema  may  be  simulated  by  a 
mediastinal  or  pleural  tumor.  An  irregular  area  of  dulness 
which  gradually  extends  in  several  directions,  the  presence 
of  some  vocal  fremitus  over  this  dull  area,  and  negative 
results  from  repeated  aspirations  are  characteristic  of  the 
latter  conditions. 

A  chronic  sacculated  empyema  which  transmits  the  car- 
diac movements  to  the  chest  wall  may  pulsate  visibly  and 
sensibly,  more  frequently  only  the  latter.  When  such  pul- 
sating empyemata  are  located  in  the  anterior  part  of  the 
chest  over  the  aortic  region,  they  may  be  confounded  with 
aortic  aneurysms.  The  similarity  of  the  radial  pulses,  the 
absence  of  systolic  murmur  over  the  pulsating  swelling,  and 
the  absence  of  signs  of  compression  of  the  nerves,  oesopha- 
gus and  trachea,  and  of  severe  boring  pain  at  the  site  of 
the  bulging  will  enable  us  to  exclude  aneurysm.  Explora- 
tory aspiration  is  not  to  be  made  in  these  cases  until  every 
other  diagnostic  aid,  including  fluoroscopic  examination, 
has  been  employed. 

Large  peripleuritic  exudates  may  simulate  sacculated 
empyemata;  but  with  such  collections  of  pus  there  is  no  evi- 
dence of  pulmonary  compression,  no  displacement  of  vis- 
cera, and  the  bulging  of  the  intercostal  spaces  is  strictly 
limited  to  the  area  of  dulness. 

The  presence  of  air  and  pus  in  the  pleural  cavity  (pyo- 
pneumothorax), the  result  of  an  infected  pneumothorax  or 
of  a  perforation  into  the  pleura  of  a  pulmonary  abscess,  is 
recognized  from  the  signs  of  fluid,  with  the  addition  of 
tympanitic  resonance  at  the  top  of  the  chest,  and  succus- 
sion.  It  is  distinguished  from  pyopneumothorax  subphreni- 
cus  by  the  fact  that  in  the  latter  the  tympanitic  resonance  is 
at  the  base  of  the  chest,  while  in  the  former  it  is  at  the  top. 
The  anamnesis  is  also  of  value  in  making  the  differentia- 
tion. (See  p.  369.)  Thus  a  history  of  intraperitoneal  sup- 
puration or  of  ulceration  of  an  intra-abdominal  organ  speaks 


198      INJURIES  AND  DISEASES  OF   THE   THORAX 

strongly  for  a  subphrenic  suppuration,  while  a  preceding 
thoracic  disease  is  strong  evidence  in  favor  of  supraphrenic 
pus  formation. 


GANGRENE  AND  ABSCESS  OF  THE  LUNG. 

Gangrene  of  the  lung  occurs  v^^hen  necrotic  areas  thereof 
undergo  putrefaction.  In  the  early  stages  of  the  process — i.  e., 
before  the  necrotic  tissue  breaks  dov^^n — the  physical  signs 
over  the  affected  portion  of  the  lung  are  similar  to  those 
which  are  afforded  by  a  pneumonic  consolidation.  Later 
on — i.  e.,  when  softening  and  liquefaction  of  the  gangrenous 
area  has  taken  place^ — the  physical  signs  are  those  of  an 
abscess  cavity,  together  with  a  fetid  odor  of  the  breath  and 
a  fetid  expectoration.  It  must  not  be  considered,  however, 
that  every  case  of  pulmonary  abscess  attended  with  fetid 
breath  and  fetid  expectoration  is  one  of  pulmonary  gan- 
grene, for  the  organisms  which  cause  putrefaction  are  always 
present  in  the  air  passages  and  very  often  they  occasion  decom- 
position of  the  purulent  contents  of  stagnant  abscess  cavities 
that  result  from  causes  other  than  gangrene,  and  so  give  rise 
to  fetid  breath  and  fetid  expectoration.  It  would  be  desira- 
ble to  distinguish  between  the  cases  in  which  the  pulmonary 
gangrene  is  the  primary  lesion  and  the  abscess  formation  the 
secondary  one,  and  those  in  which  the  abscess  is  the  pri- 
mary affection  and  the  decomposition  of  the  contents  the 
complicating  condition,  for  in  the  latter  there  is  really  no 
pulmonary  gangrene,  as  the  putrefactive  organisms  which 
are  resident  in  a  stagnant  abscess  cavity  rarely  invade  its 
walls.  Clinically  it  is  not  possible  to  separate  these  groups 
of  cases,  unless  the  history  points  to  the  presence  of  a  pul- 
monary abscess  prior  to  the  time  when  fetid  breath  and 
expectoration  were  noticed,  or  unless  there  is  in  the  history 
a  distinct  cause  for  the  gangrene  of  the  lung — e.  g.,  cardiac 
or  vascular  disease,  pneumonia,  etc. 

The  presence  of  an  abscess  in  the  lungs  is  determined 
from  the  anamnesis,  from  the  constitutional  manifestations 
of  suppuration,  by  physical  examination  of  the  chest  and 
sputum,  and  from  the  leukocyte  count. 


DISEASES  OF   THE  PLEURA   AND  LUNGS  199 

A  previous  pneumonia,  especially  of  the  aspiration  type, 
or  an  old  bronchiectasis  or  tuberculosis  are  the  most  fre- 
quent conditions  that  lead  to  the  formation  of  pulmonary 
abscess.  Less  commonly  the  latter  are  the  result  of  the 
lodgement  of  infected  emboli  in  the  lungs ;  occasionally  they 
are  due  to  a  rupture  of  an  empyema,  liver  abscess,  a  sub- 
phrenic abscess,  suppurating  echinococcus  cyst,  suppurating 
bronchial  gland,  malignant  growth  of  the  oesophagus,  or 
purulent  mediastinitis  into  the  lung. 

Percussory  and  Auscultatory  Phenomena. — The  percus- 
sory  and  auscultatory  phenomena  pointing  to  a  pulmonary 
abscess   are : 

1.  A  dull  tympanitic  resonance  over  a  circumscribed  area 
(the  tympanicity  being  the  predominant  sign),  which  dis- 
appears on  change  of  posture  and  reappears  on  assuming 
the  former  position,  or  a  tympanitic  resonance  over  a  cir- 
cumscribed area  while  the  patient  is  in  the  lying  position, 
changing  to  dulness  in  its  lower  part  and  deeper  tympanitic 
resonance  in  its  upper  zone  when  the  upright  position  is 
assumed. 

2.  Metamorphoric  breathing — i.  e.,  a  respiratory  murmur 
whose  first  part  is  vesicular  and  whose  final  part  is  amphoric 
or  bronchial.    This  is  an  almost  certain  sign  of  cavity. 

3.  Metallic  tinkle. 

4.  Amphoric  breathing,  a  very  doubtful  sign. 

It  is  important  to  compare  the  physical  signs  which  are 
obtained  before  and  after  expectoration.  Thus,  a  dulness 
and  absence  of  breathing  over  a  circumscribed  area  before 
expectoration  may  change  after  it  to  a  dull  tympany  with 
bronchial  breathing  or  one  of  its  varieties  or  amphoric 
breathing  with  metallic  tinkle. 

Expectoration. — The  expectoration  in  cases  of  pulmonary 
abscess  is  usually  of  a  fetid  character  due  either  to  gangrene 
of  the  walls  of  the  cavity  or  to  decomposition  of  the  con- 
tents. In  the  latter  instance  the  fetid  character  may  not  be 
constantly  in  evidence.  The  patient  is  often  able  to  tell  by 
taste  and  smell  the  region  of  the  lung  from  which  the  putrid 
material  is  derived.  On  standing  the  sputum  separates  into 
three  layers,  the  lowest  being  a  purulent  fluid  material  of 


200      INJURIES  AND  DISEASES  OF   THE   THORAX 

varying  consistency,  the  middle  a  turbid  fluid,  and  the 
upper  a  ropy,  frothy  material,  to  which  frothy,  purulent, 
rounded  balls  and  thready  matter  adhere.  Where  there  is 
little  secretion  from  the  bronchial  tubes  in  the  expectorated 
material,  the  pus  is  more  confluent  in  the  lowest  layer,  and 
there  are  but  few  purulent  balls  in  the  upper  layer.  The 
latter  are  suggestive  of  a  tuberculous  bronchiectasis. 

In  fresh  cavities  and  in  advancing  cavities  elastic  fibres 
are  present  in  the  expectorated  material,  and  can  be  demon- 
strated by  boiling  the  latter  in  caustic  potash. 

Various  forms  and  varieties  of  bacteria  are  present  in 
the  sputum  when  the  bronchial  tubes  share  in  the  suppura- 
tive process.  A  preponderance  of  a  single  variety  of  bac- 
teria, either  streptococcus,  or  pneumococcus,  or  staphylo- 
coccus, points  to  a  perforation  of  an  extrapulmonary  abscess 
or  empyema  into  the  lung. 

When  the  abscess  cavity  occupies  the  lower  lobes,  the 
expectoration  of  pus  usually  takes  place  at  periodic  inter- 
vals, at  which  time  large  quantities  will  be  coughed  up. 
The  discharge  is  often  influenced  by  posture  and  local  press- 
ure; this  affords  the  observer  an  idea  of  the  site  of  the  abscess. 

Roentgen  Ray. — The  Roentgen  rays  show  air-containing 
cavities  as  lighter  areas  surrounded  by  darker  ones. 

Diagnosis  of  the  Site  of  the  Abscess. — It  seems  reasonable 
to  suppose  that  by  percussion  and  auscultation  it  would  be 
comparatively  simple  to  locate  an  abscess  cavity.  It  is  to 
be  noted,  however,  that  it  is  only  the  abscesses  in  the  upper 
lobes  and  those  in  the  lower  lobes  which  are  surrounded 
by  rigid,  non-collapsible  walls,  as  the  metapneumonic  ab- 
scesses and  the  bronchiectatic  abscess  following  empyema 
that  are  likely  to  give  percussory  and  auscultatory  evidences 
of  their  presence.  Where  the  anamnesis,  profuse  expectora- 
tion, fever,  and  leukocyte  count  point  to  an  abscess  forma- 
tion the  site  of  which  cannot  be  determined  by  percussion 
and  auscultation,  it  is  well  to  remember  that  periodic  pro- 
fuse expectoration  is  more  likely  to  go  with  lower  lobe 
abscesses,  and  that  long-standing  abscesses  are  usually  in 
the  lower  lobes  behind,  and  that  the  patient  by  the  taste 
and  smell  of  the  sputum  may  be  able  to  state  from  what 


DISEASES  OF   THE  PLEURA   AND  LUNGS  201 

region  the  fetid  expectoration  is  derived,  and  finally  that  the 
x-ray  may  indicate  its  position. 

The  depth  of  the  cavity  from  the  surface  of  the  lung  can- 
not be  foretold,  even  after  exposure  of  the  lung  on  the  oper- 
ating table.  Numerous  pleuritic  friction  rales  would  seem  to 
indicate  that  the  suppuration  is  near  the  surface  of  the  lung. 

Diagnosis  of  the  Number  of  Abscesses. — Single  abscesses 
are  only  to  be  assumed  in  cases  in  which,  within  a  short 
time,  there  is  a  considerable  amount  of  lung  tissue  expec- 
torated and  when  the  signs  of  cavity  formation  persist  over 
one  and  the  same  region. 

Single  abscesses  following  croupous  pneumonia  may  be 
confounded  with  interlobar  or  other  encapsulated  empye- 
mata.  They  may  all  occasion  dulness  and  diminished 
breathing,  but  if  after  expectoration  the  dulness  changes 
to  dull  tympanicity,  and  the  breathing  becomes  metamor- 
phoric  and  there  are  elastic  fibres  in  the  sputum,  an  abscess 
is  to  be  inferred.  Multiple  abscesses  may  be  assumed  when 
cavity  symptoms  are  manifested  over  different  and  separate 
regions,  and  when  different  metamorphoric  breathing  sounds 
are  heard  over  neighboring  areas.  Bronchiectatic  cavities 
are  multiple. 

Character  of  Abscesses. — The  character  of  the  abscess, 
whether  tuberculous  or  not,  is  to  be  determined  from  the 
anamnesis,  the  duration  of  the  malady,  and  from  the  pres- 
ence or  absence  of  tubercle  bacilli  in  the  sputum.  Breaking 
down  gummata  are  rare;  their  presence  is  to  be  determined 
from  the  previous  history  of  the  patient  and  their  yielding 
to  antispecific  treatment;  other  evidences  of  syphilis  speak 
for  this  condition. 


NEOPLASMS  OF  THE  LUNG. 

Primary  Neoplasms. — Primary  neoplasms  of  the  lung 
can  only  be  diagnosed  when  they  attain  sufficient  size  to 
compress  the  mediastinal  structures  and  to  give  dulness  on 
percussion.  The  benign  growths  are  of  very  infrequent 
occurrence.     The  malignant   tumors,   sarcoma   and   carci- 


202       INJURIES  AND  DISEASES  OF   THE   THORAX 

noma,  are  more  frequently  metastatic  than  primary  growths; 
the  metastatic  sarcoma  to  primary  sarcoma  of  the  femur, 
and  the  metastatic  carcinoma  to  primary  carcinoma  of  the 
breast  being  especially  common. 

The  initial  stage  of  malignant  disease  is  attended  with 
cough,  pain  at  the  site  of  the  neoplasm,  expectoration,  and 
a  hemorrhagic  exudate  into  the  pleural  cavity.  As  the 
tumor  enlarges,  it  compresses  the  bronchi  and  causes  dysp- 
noea and  profuse  hemorrhagic,  at  times  fetid,  expectoration. 
In  cases  of  pulmonary  sarcoma  Lenhardtz  lays  stress  on 
the  presence  of  rounded,  fatty  kernels  in  the  sputum,  and 
others  dwell  on  the  significance  of  giant  vacuole  cells  (ten  to 
twenty  times  as  large  as  leukocytes)  in  the  pleuritic  exudate. 
Physical  examination  reveals  relative  or  absolute  dulness 
over  an  irregular  area  corresponding  in  its  outlines  to  the 
limits  of  the  tumor,  with  diminished  or  absent  breathing 
over  this  area  of  dulness.  X-ray  examination  shows  a  deeper 
shadow  corresponding  to  the  site  of  the  tumor.  A  radiating 
deep  shadow  is  considered  pathognomonic  of  a  tumor  of 
the  bronchi. 

Echinococcus  Cysts.^A  small  and  centrally  located  echin- 
ococcus  cyst  of  the  lung  gives  no  evidences  of  its  presence, 
and  hence  its  detection  is  not  possible.  But  as  the  cyst  grows 
and  approaches  the  surface  of  the  lung  it  occasions  a  super- 
ficial dulness,  pleural  friction  rales,  and  diminished  breath- 
ing over  a  circumscribed  area.  The  larger  cysts  compress  the 
lung  and  sometimes  the  bronchi,  and  thus  occasion  dysp- 
noea, cough,  and  expectoration  of  a  hemorrhagic  or  wine- 
colored  sputum.  In  the  absence  of  physical  signs  which  would 
point  to  the  presence  of  a  neoplasm  this  expectorated  mate- 
rial would  suggest  tuberculosis;  this  can,  however,  be  ex- 
cluded by  the  absence  of  tubercle  bacilli  in  the  sputum,  and 
by  the  lack  of  a  reaction  after  a  tuberculin  injection. 

Perforation  of  the  cyst  into  a  bronchus  is  indicated  by.  an 
expectoration  of  clear  echinococcus  fluid  in  which  booklets 
are  to  be  found,  and  sometimes  daughter  cysts.  As  the  walls 
of  the  parent  cyst  collapse  after  its  perforation,  the  physical 
signs  of  a  cavity  are  rarely  to  be  obtained.  Perforation  into 
the  pleural  cavity  is  evidenced  by  severe  pleuritic  pain  and 


DISEASES  OF   THE  PLEURA   AND  LUNGS  203 

by  the  immediate  presence  of  an  exudate  in  the  pleural 
cavity;  after  a  few  days  an  urticarial  eruption  may 
appear. 

The  presence  of  bile  in  the  expectorated  echinococcus 
material  is  evidence  of  a  primary  liver  cyst  which  has  rup- 
tured into  the  lung  and  then  into  a  bronchus. 


CHAPTER  XVL 
DISEASES  OF  THE  MEDIASTINUM. 

In  the  mediastinal  space  there  are  contained  within  narrow 
Hmits  a  number  of  important  organs — ^viz.,  the  heart  and 
the  large  bloodvessels,  the  trachea,  oesophagus,  nerves,  lym- 
phatic and  thymus  glands,  and  occasionally  accessory  lobes 
of  the  thyroid.  The  enlargement  of  any  of  these  organs, 
whether  from  inflammation  or  neoplasm,  produces  pressure 
upon  the  neighboring  structures,  and  it  is  the  evidences  of 
such  pressure  that  first  attract  attention  to  the  mediastinal 
disease. 

Thus  the  patients  complain  of  vague  pain  in  the  back, 
from  the  second  to  the  sixth  dorsal  vertebra  or  in  the  sub- 
sternal region;  of  dyspnoea,  paroxysmal  cough,  and  dys- 
phagia; and  on  physical  examination  there  is  found  a  prom- 
inence of  the  veins  of  the  face,  neck,  and  thorax,  occasionally 
oedema  of  these  parts,  and  a  rough,  blowing,  respiratory 
sound,  with  much  prolonged  expiration  over  the  interscapular 
region. 

The  severity  of  the  pressure  symptoms  is  of  course  in 
proportion  to  the  size  of  the  swelling.  When  the  latter 
attains  considerable  dimensions  there  is  a  dulness  in  the 
interscapular  region  from  the  second  to  the  sixth  dorsal 
vertebra?,  or  in  front  to  one  or  both  sides  of  the  sternum. 

These  symptoms  and  physical  signs  point  only  to  the 
presence  of  mediastinal  disease;  they  tell  us  nothing  of  the 
nature  of  the  malady. 

In  determining  this  we  are  very  materially  aided  by  a 
complete  previous  history  and  by  a  general  physical  exami- 
nation, but  quite  often  we  will  be  able  to  arrive  at  a  decision 
only  by  a  process  of  exclusion. 


DISEASES  OF   THE  MEDIASTINUM 


205 


GLANDULAR  ENLARGEMENT. 

Glandulaj"  enlargement  will  be  suggested  if  there  is  swell- 
ing of   the  glands  in  other  regions — e.g.,  the  neck,  groin, 


Fig.  105 


Carcinoma  of  the  mediastinum.    Note  the  prominence  of  the  veins  of  the  neck  and 
thorax.    (Curschmann.) 


206       INJURIES  AND  DISEASES  OF   THE   THORAX 

abdomen,  and  axillae.  With  tuberculosis  of  the  glands  the 
swelling  is  rarely  so  great  as  to  cause  pressure  symptoms, 
and  there  are  very  apt  to  be  other  evidences  of  tuberculosis 
in  the  lungs,  cervical  glands,  etc.  With  syphilis  of  the 
glands  there  is  a  history  of  an  initial  chancre,  and  there  are 
apt  to  be  other  lesions  of  this  disease  in  the  bones,  skin,  and 
mucous  membranes.  With  leuksemic  and  pseudoleukeemic 
glandular  enlargement  there  are  characteristic  changes  in 
the  blood  and  glandular  masses  are  present  in  other  regions; 
and  with  sarcoma  and  carcinoma  of  the  glands  there  is, 
as  a  general  rule,  a  primary  growth  in  the  breast,  lower 
extremities,  etc. 

If  the  glandular  swelling  is  inflammatory  the  pressure 
symptoms  will  not  be  very  pronounced,  but  when  healing 
takes  place  the  contraction  which  follows  may  result  in 
traction  diverticula  of  the  bronchi  or  oesophagus  (see  p. 
210),  or  in  adhesions  to  the  pleura  and  lungs.  The  neo- 
plastic, pseudoleuksemic,  and  leukeemic  glandular  enlarge- 
ment is  usually  very  considerable  and  the  evidences  of 
pressure  are  consequently  very  marked. 


NEOPLASMS. 

Benign  neoplasms  of  the  mediastinum  are  infrequent, 
the  more  common  being  the  branching  lipoma  and  dermoid 
cysts,  and  the  more  rare  the  echinococcus  and  simple  cysts. 
Their  slow  growth  and  the  absence  of  cachexia  and  metas- 
tases differentiate  them  from  malignant  growths,  and  the 
absence  of  the  classical  symptoms  of  aneurysm  distinguishes 
them  from  vascular  tumors.  The  possibility  of  the  tumor 
being  a  diseased  accessory  thyroid  lobe  should  always  be 
borne  in  mind. 

Tumors  which  originate  in  the  lungs,  pleurae,  oesophagus, 
or  bloodvessels,  and  secondarily  invade  the  mediastinum, 
usually  give  some  evidences  from  the  primarily  affected 
viscus  which  leads  to  the  correct  diagnosis.  In  the  absence 
of  such  signs  their  differentiation  from  primary  mediastinal 
tumors  and  diseases  will  be  very  difficult,  if  not  impos- 
sible. 


DISEASES  OF   THE  MEDIASTINUM 


207 


SUPPURATIVE  MEDIASTINITIS. 

The    presence    of   a   suppurative    mediastinitis    may   be 
assumed  if  to  the  evidences  of  pressure  upon  the  mediastinal 

Fig.  106 


Aneurysm  of  the  arch  of  the  aorta,  giving  the  classical  signs  of  this  disease  and  com- 
pressing the  structures  in  the  upper  mediastinal  region.    (Curschmann.) 


-VIZ. 


organs  there  are  added  the  symptoms  of  pus  formation- 
fever,  chills,  sweating,  rapid  pulse,  throbbing  pain  in  the 


208        INJURIES  AND  DISEASES  OF  THE  THORAX 

chest  and  back,  and  a  high  leukocyte  count.  As  such  sup- 
puration is  never  a  primary  process,  but  always  follows 
perforation  or  ulceration  of  the  organs  in  the  mediastinum 
or  neck,  or  suppuration  of  the  vertebrae,  or  some  acute 
infectious  disease  like  typhoid  fever,  pneumonia,  smallpox, 
etc.,  we  should  always  try  to  ascertain  the  nature  and  the 
site  of  its  primary  cause. 


CHAPTER   XVII. 

DISEASES  OF  THE  (ESOPHAGUS. 

The  oesophagus  is  a  muscular  tube,  the  function  of  which 
is  to  transport  food  from  the  oropharynx  into  the  stomach, 
and  the  first  result  of  its  disease  is  consequently  a  disturb- 
ance of  this  function — i.  e.,  dysphagia.  Those  surgical  dis- 
eases as  retropharyngeal  abscess,  tumors  of  the  oropharynx, 
tonsils,  and  cervical  glands,  laryngeal  ulcerations,  etc.,  which 
prevent  ingesta  from  reaching  the  oesophagus  and  so  inter- 
fere with  swallowing,  usually  afford  other  clinical  evidences 
besides  the  dysphagia — viz.,  nasal  voice,  laryngeal  cough  and 
breathing,  disturbances  of  the  spine,  etc. — that  should  prompt 
the  examiner  to  look  carefully  into  the  mouth  and  larynx  for 
the  cause  of  the  difficulty.  Once  the  food  enters  into  the 
oesophagus  its  further  passage  downward  into  the  stomach 
depends  upon  the  integrity  of  the  muscular  wall  of  the  tube 
and  upon  the  calibre  of  its  canal. 

DISTURBANCES  IN  ACTION. 

Disturbances  in  the  action  of  the  muscular  fibres  may  be 
in  the  nature  of  overaction  or  paralysis,  the  former  affecting 
most  frequently  the  fibres  around  the  cardiac  orifice  and 
resulting  in  what  Mikulicz  has  described  as  cardiospasm.^ 

DISTURBANCES  IN  LUMEN. 

Disturbances  in  the  lumen  of  the  oesophagus  may  be  in 
the  nature  of  a  total  or  partial  occlusion,  as  by  foreign  bodies, 

1  Under  normal  conditions  the  cardiac  orifice  opens  automatically  during  the  act 
of  swallowing,  but  in  cardiospasm  it  remains  closed  and  must  be  overcome  by  the 
forcible  contraction  of  the  muscular  wall  of  the  cesophagus,  with  consequent  hyper- 
trophy and  dilatation  of  it. 

14 


210        INJURIES  AND  DISEASES  OF   THE   THORAX 

or  of  a  contraction  (stenosis)  or  dilatation.  The  stenosis  may 
be  due  to  simple  or  malignant  ulceration  or  stricture  of  the 
oesophageal  wall  or  to  compression  of  the  organ  by  neigh- 
boring neoplasms,  aneurysms,  etc.  Dilatation  of  the  lumen 
may  be  present  throughout  the  entire  extent  of  the  organ — 
e.  g.,  after  paralysis  of  the  muscular  coat  (as  occurs  in  bulbar 
paralysis);  or  it  may  be  limited  to  a  portion  of  the  tube — 
e.  g.,  above  a  stricture  or  spasm;  or  it  may  be  confined  to  a 
part  of  the  circumference  of  the  tube — e.  g.,  a  circumscribed 
pouch-like  protrusion  or  bulging  of  the  wall  (a  diverticulum).^ 

Clinical  Evidences. — The  clinical  evidences  resulting  from 
partial  or  complete  occlusion  by  foreign  bodies,  from  sten- 
osis, from  dilatation,  and  diverticula,  and  from  spasm  are 
about  the  same.  The  patients  complain  of  dysphagia,  re- 
gurgitation of  ingested  material  immediately  or  some  time 
after  their  taking,  and  inanition.  The  dysphagia  in  the 
early  stages  of  the  disease  is  noticed  only  when  solid  food 
is  taken,  but  later  on  it  is  also  present  when  liquids  are 
ingested.  The  diagnosis  of  the  nature  of  the  malady  must 
be  made  by  a  careful  examination. 

The  examination  should  always  be  preceded  by  the  elici- 
tation  of  a  complete  previous  history,  in  which  it  is  espe- 
cially essential  to  ascertain  the  age  of  the  patient,  the 
duration  and  character  of  the  initial  symptoms;  whether 
the  individual  was  ever  afflicted  with  syphilis  or  severe 
typhoid  fever,  in  the  course  of  which  oesophageal  ulcerations 
and  dysphagia  were  in  evidence;  whether  caustic  acids  or 
alkalies  or  foreign  bodies  have  been  swallowed,  and  whether 
any  other  symptoms  have  attended  the  dysphagia — e.  g., 
aphonia,  boring  pain  in  the  sternum  or  vertebrae,  dyspnoea, 
profuse  fetid  expectoration  of  purulent  material  and  food. 
All  these  data  are  essential  for  differential  diagnosis.  A 
spontaneous  onset  of  the  symptoms  suggests  a  carcinoma- 
tous or  syphilitic  stricture  or  a  diverticulum. 

The  physical  examination  is  made  with  the  oesophageal 

1  Diverticula  are  divided  into  the  pulsion  and  traction  varieties;  tlie  former  result 
from  increased  pressure  vpithin  the  cesophagus  upon  a  weakened  area  of  its  wall,  and 
are  located  mostly  in  the  cervical  portion  of  the  tube  ;  the  latter  are  due  to  traction 
upon  the  wall  of  the  oesophagus  by  adhesions,  bands,  etc.,  and  are  located  in  any 
portion  of  the  organ. 


DISEASES  OF   THE  (ESOPHAGUS  211 

bougie,  the  oesophagoscope,  the  rr-ray,  and  by  percussion 
and  auscuhation  over  the  posterior  mediastinum,  including 
auscultation  of  the  oesophagus  during  deglutition. 

The  use  of  the  oesophageal  bougie  will  usually  determine 
the  patency  or  non-patency  of  the  oesophageal  lumen.  The 
larger-sized  bougies  are  first  to  be  employed,  and  if  their 
passage  is  obstructed  smaller  and  smaller  ones  are  to  be 
used  until  one  is  passed  or  the  non-patency  of  the  canal  for 
bougies  is  established.  Arrest  of  the  instrument  is  usually 
due  to  stenosis,  but  it  is  not  to  be  forgotten  that  diverticula 
may  likewise  interfere  with  its  passage.  In  this  case,  how- 
ever, a  change  in  the  patient's  position,  or  throwing  his 
head  far  back  or  to  one  side,  may  enable  the  obstruction  to 
be  overcome  and  the  sound  to  be  passed  into  the  stomach. 
It  is  to  be  further  noted  that  diverticula  may  arrest  the 
passage  of  small  bougies,  whereas  larger  ones  easily  pass 
into  the  stomach.  One  trial  with  the  bougie  is  therefore  not 
sufficient.  Repeated  attempts  with  large  and  small-sized 
instruments  should  be  made,  always  gently,  and  with  the 
patient's  head  in  various  positions. 

If  an  obstruction  of  the  lumen  and  its  site  has  been  estab- 
lished, the  next  concern  is  to  determine  its  nature.  For 
this  the  anamnesis  and  the  age  of  the  patient  furnish  valua- 
ble data,  and  they  are  to  be  supplemented  by  those  which 
are  afforded  by  oesophagoscopy,  a:-ray,  and  general  physical 
examination. 

Thus  a  history  of  having  swallowed  a  foreign  body  will 
point  to  partial  or  complete  obturation  by  such  foreign 
material;  a  history  of  having  swallowed  carbolic  acid,  or 
caustic  lye,  or  other  corrosive,  will  indicate  benign  cica- 
tricial stenosis;  a  previous  history  of  syphilis  or  other  evi- 
dences of  this  disease  will,  in  the  absence  of  another  cause 
for  the  symptoms,  suggest  a  sphilitic  ulceration  with  cica- 
tricial stenosis;  whereas  advanced  years  (above  forty)  with 
rapidly  increasing  stenosis,  vomiting  of  blood,  and  cachexia 
and  emaciation  out  of  proportion  to  the  degree  of  stenosis, 
will  point  strongly  to  malignant  neoplasm  of  the  organ.  It 
is  infrequent  to  find  fragments  of  the  neoplasm  in  the  vomitus, 
but  when  they  are  present  they  substantiate  the  diagnosis.  A 
very  gradual  onset  of  symptoms,  with   a  profuse  expecto- 


212      INJURIES  AND  DISEASES  OF   THE   THORAX 

ration  of  mucus,  a  feeling  of  fulness,  with  colicky  pains^  in 
the  neck  relieved  by  vomiting,  a  difficulty  in  swallowing 
the  first  parts  of  a  meal,  while  the  rest  of  it  passes  down 
easily,  and  finally  a  pronounced  dysphagia  and  regurgitation 


Fig. 107 


Pulsion  diverticula  of  the  oesophagus.    (Kiinig.) 

of  large  amounts  of  unmodified  ingesta,  some  of  which  may 
have  been  taken  several  days  before,  suggest  a  pulsion 
diverticulum;  the  diagnosis  is  confirmed  by  the  appearance 
of  a  tumor  in  the  neck  after  eating,  and  its  disappearance 
after  regurgitation  or  expression, 


DISEASES  OF   THE  (ESOPHAGUS 


213 


The  absence  of  data  pointing  to  any  of  the  above  causes 
for  the  stenotic  symptoms,  and  especially  if  the  patient  is 
young  and  the  obstruction  is  at  the  cardiac  orifice,  will 
permit  of  the  assumption  of  a  cardiospasm.  Should  the 
individual  show  evidences  of  hysteria  and  the  site  of  the 
stenosis  change  from  time  to  time,  an  hysterical  spasm  may 
be  thought  of,  but  the  diagnosis  in  either  case  must  be  veri- 
fied by  the  oesophagoscope. 

If  the  physical  examination  reveals  a  solid  or  cystic  tumor 
in  the  neck,  and  the  stenosis  is  in  the  cervical  portion  of  the 


Fig. 108 


Pulsion  diverticulum,  empty.    (Observed  in  Billroth's  clinic.)    (Von  Bergmann.) 


tube,  a  compression  of  the  oesophagus  by  the  neoplasm  may 
be  inferred;  similarly,  intense  pain  in  the  vertebrae,  with  dul- 
ness  in  the  mediastinum,  systolic  murmur,  thrill  and  retarda- 
tion of  the  pulse  at  the  wrist,  suggest  an  aortic  aneurysm 
with  oesophageal  compression.  Again,  dyspnoea,  loud  harsh 
breathing  over  the  root  of  the  lung,  dulness  in  the  posterior 
mediastinum,  and  absent  breathing  over  one  or  more  pul- 
monary lobes  point  to  a  mediastinal  neoplasm  compressing 
the  oesophagus. 


214      INJURIES  AND  DISEASES  OF   THE   THORAX 

A  careful  physical  examination,  with  a  close  study  of 
the  anamnesis,  will  thus  throw  much  light  on  the  nature  of 
oesophageal  disease.  Positive  conclusions  can  of  course 
only  be  formed  from  seeing  and  feeling  the  diseased  parts. 
The  latter  is  only  possible  in  case  the  lesion  is  located  in 
the  cervical  portion  of  the  organ,  but  the  former  is  at  our 
disposal  through  use  of  the  oesophagoscope  and  a:;-ray. 

Employment  of  (Esophagoscope. — The  systematic  em- 
ployment of  the  oesophagoscope  and  x-ray  has  but  recently 
come  into  practice,  and  with  perfection  in  the  technique 


Fig. 109 


Pulsion  diverticulum,  filled.    (Observed  in  Billroth's  clinic.)   (Vo-n  Bergmann.) 

of  their  use,  and  greater  skill  in  the  interpretation  of  the 
findings  afforded  by  them,  earlier  and  better  diagnoses  will 
result.  The  nature  of  a  stenosis,  the  orifice  of  a  diverticulum, 
and  the  presence  of  a  cardiospasm  are  easily  studied  and 
observed  through  the  oesophagoscope,  while  the  cahbre  and 
course  of  the  organ  are  just  as  easily  to  be  seen  with  the 
fluoroscope  after  its  canal  has  been  coated  with  bismuth. 

The  picture  afforded  by  the  oesophagoscope  in  cases  of 
cicatricial  strictures  due  to  swallowing  a  corrosive  material 
is  as  follows:    In  the  cervical  and  upper  thoracic  portions 


DISEASES  OF   THE  (ESOPHAGUS 


215 


of  the  canal  numerous  ribbon-like,  longitudinal,  speckled 
white  scars  are  seen.  Nearest  to  the  stricture  these  scars 
are  the  most  numerous.     The  entrance  to  the  stricture  is 


Fig.  m 


{    \ 


CEsophagoscopes. 


shaped  like  a  funnel,  and  the  strictured  portion  rarely  has 
respiratory  mobility  (von  Haeker). 

During  the  early  stages  of  carcinoma  the  oesophagoscope 


216      INJURIES  AND  DISEASES  OF   THE   THORAX 

shows  an  infiltration  of  the  mucosa,  which  is  recognized  by 
its  rigidity  and  respiratory  immobiHty  or  by  a  circumscribed 
protrusion  of  the  affected  area,  the  mucous  membrane  over 
this  being  paler  or  more  cyanotic  than  that  in  other  parts, 
or  studded  with  numerous,  small,  papillary  excrescences. 
If  the  carcinoma  extends  more  beneath  the  mucous  mem- 
brane the  latter  may  be  thrown  into  rigid  longitudinal  folds, 
with  irregular,  funnel-sHaped  appearance  of  the  lumen.  If 
bloody  mucus  appears  in  the  lumen  of  the  strictured  por- 
tion, ulceration  is  probably  present.  Very  often  patches 
of  leukoplakia  are  seen  on  the  mucous  membrane,  and, 
when  ulceration  occurs,  vesicles  are  noted  which  by  their 
confluence  and  breaking  down  leave  ulcers.  The  ulcer 
appears  like  a  strawberry,  covered  with  reddish-gray  granu- 
lations, and  bleeds  easily.  In  cases  of  doubt  a  piece  of  the 
ulcer  may  be  evulsed  for  microscopic  examination  (von 
Haeker). 

In  every  case  of  oesophageal  stenosis  there  is  some  reten- 
tion of  mucus  and  ingested  food  within  the  oesophageal 
canal  above  the  stricture.  This  leads  to  dilatation  of  the 
lumen  of  the  organ,  and  in  its  extreme  form  such  dilatation 
may  be  confounded  with  a  deep-seated  traction  diverticulum. 
As  a  rule,  the  pre vious^^history' (absence  of  a  cause  for  traction 
diverticulum — e.  g.,  mediastinal  disease),  the  age  of  the 
patient,  and  examination  with  bougies  will  determine  the 
presence  of  a  stricture,  or  physical  examination  will  reveal 
a  cause  for  compression  of  the  organ,  and  thus  a  diverticu- 
lum will  be  excluded.  The  two  conditions  may  sometimes 
be  differentiated  by  passing  a  stomach  tube  with  lateral  open- 
ings into  the  diverticulum  or  supposed  diverticulum  and 
another  alongside  of  it  into  the  stomach.  (This  in  itself 
dismisses  the  possibility  of  stricture  or  stenosis.)  If  a  colored 
fluid  is  now  poured  into  the  former  and  no  diverticulum  is 
present,  it  will  trickle  down  into  the  stomach,  from  which  it 
may  be  recovered  by  aspiration;  if  a  diverticulum  is  present 
the  fluid  finds  its  way  into  it,  and  nothing  is  recovered  from 
the  stomach,  or  only  the  overflow  from  the  diverticulum. 
The  skiagraph  further  helps  to  differentiate  them,  while  the 
oesophagoscope  makes  the  diagnosis  positive. 

A  perforation  of  the  oesophagus  into  the  lung  or  posterior 


DISEASES  OF   THE  (ESOPHAGUS  217 

mediastinum  is  followed  by  evidences  of  abscess  in  these 
parts,  which  gives  the  signs  already  described  as  due  to 
these  lesions. 

Benign  tumors  of  the  oesophagus,  especially  polypi,  cause 
no  disturbances  while  they  are  small;  when  large  they  pro- 
duce obturation  and  give  rise  to  the  usual  symptoms  thereof. 
Their  diagnosis  is  to  be  made  with  the  oesophagoscope. 


PART    IV. 

DIAGNOSIS  OF  INJURIES  AND  DISEASES  OF  THE 
ABDOMINAL  WALL  AND  VISCERA. 


CHAPTER   XVIII. 

GENERAL  REMARKS   ON  ABDOMINAL   DIAGNOSIS  AND 
EXAMINATION. 

The  introduction  of  aseptic  and  antiseptic  methods  of 
operating  opened  up  new  fields  of  usefulness  to  the  surgeon, 
and  in  none  of  them  has  he  gained  greater  glory  than  in  the 
domain  of  abdominal  diseases.  By  incessant  study,  labor, 
and  research  he  has  brought  his  technical  skill  in  dealing 
with  the  abdominal  viscera  to  a  high  plane  of  efficiency, 
but  his  diagnostic  ability  has  not  been  similarly  advanced, 
he  having  need  of  much  improvement  in  this  direction  before 
he  achieves  the  perfection  that  he  has  acquired  in  his  technical 
accomplishments.  At  the  present  time  he  must  still  resort 
to  laparotomy  to  aid  him  in  diagnosis  during  the  early  stages 
of  some  of  the  abdominal  diseases,  though  he  is  well  aware 
that  such  exploratory  laparotomy  is  a  confession  of  diag- 
nostic weakness  on  his  part.  It  is  a  weakness,  however, 
that  it  is  neither  shameful  nor  sinful  to  acknowledge.  If 
one  takes  into  account  the  close  anatomical  proximity  and 
similar  physiological  function  of  many  of  the  important 
organs  within  the  abdomen,  it  is  not  to  be  wondered  at 
that  the  surgeon  often  finds  himself  in  a  quandary  as  to 
the  exact  character  of,  nay,  even  as  to  the  organ  which  is 
involved  in  the  diseased  process.  In  far-advanced  cases  no 
well-trained  surgeon  will  need  an  exploratory  laparotomy 


220     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

to  aid  him  in  establishing  a  diagnosis.     Little  benefit,  how- 
ever, is  to  be  derived  by  the  patient  from  surgical  interfer- 


Fig.  112 

19 

36                1 

Topography  of  thoracic  and  upper  abdominal  organs.  (Toldt.)  1.  Left  common 
carotid  artery.  2.  Left  innominate  vein.  3  and  4.  Pulmonary  and  costal  pleura.  5 
and  23.  Pericardial  layer  of  the  pleura.  6.  Pericardium.  7.  Left  lateral  ligament  of 
the  liver.  8.  Diaphragmatic  pleura.  9.  Fundus  of  stomach.  10.  Cardiac  end  of 
stomach.  11.  Anterior  margin  of  spleen.  12.  Gastrolienal  ligament.  13.  Bed  of 
spleen.  14.  Colicophrenic  ligament.  15.  Splenic  flexure  of  the  colon.  16.  Great 
omentum.  17.  Transverse  colon.  18.  Posterior  layer  of  great  omentum.  19.  Dome  of 
pleura.  20.  Innominate  artery.  21.  Right  innominate  vein.  22.  Superior  vena  cava. 
24.  Right  lung.  25.  Left  hepatic  lobe.  26  and  27.  Gastrohepatic  omentum.  28.  Hepato- 
duodenal ligament.  29.  Gall-bladder.  30.  Hepatocolic  ligament.  31.  First  portion 
of  duodenum.  32.  Pylorus.  33.  Hepatic  flexure  of  colon.  34.  Bursa  omentalis.  35. 
Transverse  mesocolon.    36.  Trachea. 


ABDOMINAL   DIAGNOSIS  AND  EXAMINATION      221 

ence  in  such  late  stages  of  disease;  if  any  good  is  to  be  con- 
ferred by  operative  efforts  the  diagnosis  must  be  made  in 

Fig. 113 


Topography  of  the  abdominal  viscera.  Note  relation  of  the  organs  to  the  costal 
arch  and  the  abdominal  parietes.  1.  Xiphoid  process.  2.  Costal  arch.  3.  Left  lobe 
of  liver.  4.  Stomach.  5.  Great  omentum.  6.  Small  intestines.  7.  Sigmoid  flexure 
of  colon.  8  and  10.  Parietal  peritoneum.  9.  Falciform  ligament  of  the  liver.  11. 
Round  ligament  of  the  liver.  12.  Right  lobe  of  the  liver.  13.  Fundus  of  the  gall- 
bladder. 14.  Hepatic  flexure  of  the  colon.  15.  Ascending  colon.  16.  Csecum.  17. 
Lateral  umbilical  fold.    18.  Median  umbilical  fold. 


the  early  stages  of  the  malady,  and  at  the  present  day  such 
early  diagnosis  frequently  needs  the  help  of  an  exploratory 


incision. 


222     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

The  immunity  against  infection  conferred  upon  our 
patients  by  a  strict  observance  of  the  aseptic  and  antiseptic 
methods  of  operating  has  reduced  the  dangers  of  such  ex- 
ploratory incisions  to  a  minimum;  why  then  should  we  deny 
our  patients  the  great  benefits  which  are  to  be  derived  from 
exploratory  incision  in  making  an  early  correct  diagnosis? 
We  do  not  hesitate  to  expose  a  tumor  of  doubtful  character 
when  it  is  located  in  the  soft  parts,  why  should  we  hesitate 
to  do  likewise  in  doubtful  diseases  of  the  abdomen  when 
the  risk  is  in  nowise  greater?  It  is  to  be  hoped  that  con- 
tinued exploration  will  throw  the  much-needed  light  upon 
the  early  stages  of  the  diseased  conditions  of  the  abdominal 
organs  that  it  has  thrown  upon  the  early  stages  of  bone 
and  joint  and  appendicular  disease,  and  that  in  the  not  far 
distant  future  we  may  be  able  to  make  early  diagnoses  with- 
out the  aid  of  an  abdominal  incision.  But  at  the  present 
time  the  surgeon  must,  in  the  early  stages  of  some  of  the 
abdominal  diseases,  resort  to  diagnostic  laparotomy;  and  the 
author  strongly  seconds  the  opinion  expressed  by  Dr.  Wm. 
H.  Mayo  in  regard  to  the  diagnosis  of  the  diseased  conditions 
occurring  in  the  right  hypochondriac  region — ^viz.,  ''that 
the  essential  point  to  determine  in  a  given  case  is  whether 
it  should  be  treated  medically  or  surgically,  and  not  so 
much  the  exact  character  or  starting  point  of  the  diseased 
process." 

Though  I  have  thus  pleaded  for  early  exploration  in 
doubtful  diseases  of  the  abdominal  viscera,  I  do  not  by  any 
means  wish  it  to  be  inferred  that  a  diagnosis  cannot  be  made 
in  any  other  way.  On  the  contrary,  the  rule  is  that  a  careful 
history  and  a  painstaking  physical  examination  will  lead  to 
a  correct  diagnosis. 

The  method  of  taking  the  patient's  history  has  already 
been  dwelt  upon,  and  in  the  following  pages  the  method  of 
making  a  physical  examination  of  the  abdomen  will  be 
briefly  described. 

Examination  of  the  abdomen  is  made  by  inspection, 
palpation,  percussion,  and  auscultation,  and  in  some  in- 
stances by  exploratory  puncture. 

Inspection. — For  inspection  the  patient  should  be  in  the 
upright,    dorsal    recumbent,    lateral    prone    or   knee-elbow 


ABDOMINAL  DIAGNOSIS  AND  EXAMINATION      223 

position,    and    note    should    be    taken    of    the    following 
points : 

1.  The  presence  of  scars  or  strice  in  the  skin  due  to  long- 
continued  distention — e.  g.,  by  pregnancy,  ascites,  etc. 

2.  The  movement  of  the  abdominal  wall  with  respiration; 
respiratory  immobility  points  to  a  local  or  to  a  general  pain- 
ful peritoneal  inflammation. 

3.  The  presence  of  fat  accumulation;  when  this  is  exces- 
sive it  is  especially  abundant  on  the  summit  of  the  abdomen, 
but  the  umbilicus  is  not  thereby  elevated. 

4.  The  presence  of  cedema  of  the  abdominal  walls.  When 
present  it  is  especially  apparent  in  the  most  dependent  por- 
tions— viz.,  in  the  flanks  and  groins  when  the  patient  is 
recumbent;  it  pits  on  pressure  and  it  shifts  with  a  change 
of  tlie  patient's  position.  It  is  to  be  noted,  however,  that 
the  umbilicus  remains  retracted.  If  there  is  a  coincident 
oedema  of  other  regions  of  the  skin,  a  general  circulatory 
disturbance  is  to  be  suspected.  If  it  is  confined  to  one  area 
of  the  abdominal  wall,  a  local  inflammation  of  the  latter  or 
of  an  underlying  intraperitoneal  viscus  is  likely  to  be  present. 

5.  The  presence  of  intestinal  distention.  This  may  be 
local  or  general,  and  if  there  is  also  an  increased  peristalsis 
it  speaks  for  intestinal  obstruction.  A  painful  distention 
of  one  coil  of  intestine  alternating  with  its  collapse  (intes- 
tinal erection)  is  a  pathognomonic  sign  of  a  chronic  intes- 
tinal stenosis  just  below  the  erected  coil. 

6.  The  presence  of  ascites.  When  there  is  an  accumula- 
tion of  considerable  amounts  of  fluid  in  the  peritoneal  cavity 
the  flanks  are  ballooned  out,  the  abdomen  is  barrel-shaped, 
and  the  umbilicus  protrudes.     (See  Fig.  124.) 

7.  Changes  in  the  cutaneous  circulation.  A  distention 
of  the  veins  along  the  side  of  the  abdomen  indicates  com- 
pression or  thrombosis  of  the  vena  cava  inferior.  A  dis- 
tention of  the  veins  around  the  umbilicus  (caput  medusae) 
speafe  for  obstruction  by  compression  or  thrombosis  of 
the  portal  circulation.     (See  Figs.  114,  115,  and  116.) 

Visual  inspection  is  aided  by  (1)  fluoroscopy,  by  which  the 
contour  and  consistency  and  outlines  of  tumors  and  organs 
may  be  determined;  (2)  by  gastrodiaphany,  by  which  the 
outlines  of  the  stomach  and  the  presence  and  limits  of  the 


224     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

neoplasm  or  exudate   around  the  organ  are  fixed;   (3)   by 
oesophagoscopy,  and  (4)  by  cystoscopy. 

Palpation.— For  palpation  the  patient  is  usually  placed 
in  the  dorsal  recumbent  position  with  the  limbs  slightly 
drawn  up.  The  knee-elbow  position  and  Trendelenburg's 
position  afford  considerable  aid  in  palpating  the  pelvic 
organs  and  pelvic  neoplasms.     Strong  flexion  of  the  thorax 

Fig.  114 


Enlargement  of  the  superficial  veins  along  the  side  of  the  abdomen  from 
obstruction  of  the  inferior  vena  cava. 


and  lower  limbs  upon  the  abdomen  (Gerster)  often  facilitates 
palpation  of  the  organs  and  neoplasms  in  the  upper  abdominal 
region.  The  dorsal  recumbent  position  with  moderate  eleva- 
tion of  one  extended  limb  (Meltzer)  is  of  service  in  palpation 
of  the  corresponding  iliac  fossa.  The  lateral  prone  position 
sometimes  renders  palpation  more  easy. 


ABDOMINAL  DIAGNOSIS  AND  EXAMINATION     225 

Before  resorting  to  palpation  the  bladder  and  rectum 
should  be  emptied.  The  greatest  barriers  to  satisfactory 
abdominal  palpation  are  rigidity  and  excessive  adiposity  of 
the  abdominal  walls.  The  former,  except  when  due  to 
peritonitis,  can  often  be  overcome  by  directing  the  patient 
to  take  deep  respirations  and  keep  his  mouth  open.     Mus- 

FiG.lJS 


Eulargemeut  of  the  superficial  veins  around  umbilicus  from  obstruction 
of  the  portal  vein. 


cular  relaxation  can  sometimes  be  brought  about  by  placing 
the  patient  in  a  warm  bath,  and,  where  everything  else  fails, 
by  the  administration  of  an  anaesthetic. 

By  palpation  note  is  to  be  taken  of: 

1.  Irregularities  in  the  abdominal  wall.  If  these  are 
due  to  fat,  the  masses  are  elastic,  soft,  and  lobulated,  and 

15 


226     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

generally  distributed.  If  they  are  due  to  new-growths,  they 
are  local,  and  become  more  prominent  on  contraction  of 
the  abdominal  muscles  (e.  g.,  by  straining), 

2.  Rigidity  of  the  abdominal  walls.  This  may  be  local 
or  general,  and  indicates  a  circumscribed  or  diffuse  peri- 
toneal inflammation,  or  reflex  muscular  contraction '  with- 
out any  organic  basis. 

Fig. 116 


Enlargement  of  superficial  abdominal  veins  from  portal  obstruction. 


3.  The  presence  of  peritoneal  crepitation.  This  results 
from  the  rubbing  upon  one  another  of  adjacent  fibrin- 
covered  surfaces  of  peritoneum. 

4.  The  presence  of  the  fremitus  of  hydatid  disease.  This 
is  rarely  obtained;  it  is  due  to  the  impact  of  the  hydatid 
cyst  contents  against  the  cyst  wall  and  is  most  frequently 
found  in  superficial  hydatid  cysts  of  the  liver. 


ABDOMINAL  DIAGNOSIS  AND  EXAMINATION      227 

5.  The  presence  of  increased  peristaliic  waves.  These 
speak  for  intestinal  obstruction.  Of  special  import  is  intes- 
tinal erection  (i.  e.,  a  sudden  painful  distention  of  one  loop  of 
bowel,  which  is  pathognomonic  of  chronic  intestinal  stenosis. 

6.  The  presence  and  consistency  of  abdominal  tumors. 

7.  The  mobility  of  abdominal  tumors  or  dislocated  viscera. 

Mobility  may  be  active,  passive,  or  respiratory  in  char- 
acter; it  is  materially  hindered  or  even  entirely  suspended 
by  peritoneal  adhesions. 

Fig.  117 


Gei'ster's  position  (thorax  and  lower  limbs  strongly  flexed  upon  the  abdomen) 
for  palpation  of  epigastric  region. 


All  intraperitoneal  tumors  have  some  respiratory  mobility; 
this  is  interfered  with  by  paralysis  of  the  diaphragm  and 
by  large  amounts  of  fluid  in  the  pleural  cavities. 

Tumors  of  the  stomach,  of  the  small  and  large  intestines 
and  their  mesenteries  (except  when  located  at  the  root  of 
the  latter),  of  the  ovary,  and  uterus,  and  a  wandering  spleen 
have  active  mobility,  the  range  of  which  depends  on  the 
length  of  their  pedicle  and  on  the  mobility  of  the  organs 
from  which  such  tumors  spring.  Some  of  them  move  in 
arcs  of  circles  or  in  ellipses,  the  centre  of  which  lies  in  the 
affected  organ.     The  gall-bladder  is  very  freely  movable 


228     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

when  it  is  connected  to  the  Hver  by  a  long  mesentery,  but 
when  it  is  closely  attached  to  the  liver  it  has  no  independent 
mobility. 

Retroperitoneal  tumors  have  no  respiratory  mobility. 
They  may  have  active  mobility — e.  g.,  a  floating  kidney. 
Pancreatic  swellings  and  tumors  have  no  mobility. 

Intraperitoneal  or  extraperitoneal  adherent  exudates 
have  no  mobility. 

Pig.  118 


Meltzer's  position  (m.jderatu  elevatinu  of  one  exteuded  limb)  for  palpation  of  the 

iliac  fo&sa. 


Passive  mobility  is  enjoyed  by  pedunculated  tumors,  or 
dislocated  viscera  with  long  mesenteries — e.  g.,  ovarian 
tumors,  wandering  spleen,  etc. 

8.  The  relation  of  the  distended  stomach  and  colon  to 
dislocated  viscera  or  neoplasms.  The  stomach  is  best  dis- 
tended by  air  injected  through  a  stomach  tube  with  a  David- 
son syringe.  The  large  intestine  is  best  distended  through 
a  rectal  tube,  which  is  passed  about  six  inches  into  the  bowel 
and  whose  outer  end  is  connected  with  the  nozzle  of  an 
inverted  bottle  filled  with  charged  COj  water. 

Minkowski  has  shown  that  after  the  stomach  and  colon 


ABDOMINAL  DIAGNOSIS  AND  EXAMINATION     229 

are  distended,  abdominal  tumors  tend  to  recede  to  those 
parts  of  the  cavity  in  which  are  situated  the  organs  from 
which  they  arise.  A  distended  stomach  pushes  the  Hver 
and  gall-bladder  upward  under  the  ribs;  the  spleen  down- 
ward and  to  the  left;  the  transverse  colon  and  omentum 
downward.  The  lesser  curvature  moves  upward  under  the 
ribs.  The  kidneys  remain  unaffected  by  gastric  distention, 
but  are  pushed  upward  and  backward  by  a  distended  colon. 

A  distended  stomach  and  large  intestine  cover  over  pan- 
creatic tumors  with  the  exception  of  those  which  push  for- 
ward between  the  stomach  and  bowel. 

Percussion. — By  'percussion  we  should  determine  (a)  the 
limits  of  dulness  and  flatness  of  the  solid  organs,  neoplasms, 
or  exudates,  and  (6)  the  limits  of  gastric,  intestinal  and 
colonic  tympany. 

Diminution  of  liver  or  splenic  dulness  from  helow  is  usually 
due  to  a  distended  stomach  or  intestine. 

Diminution  of  liver  or  splenic  dulness  ahove  and  below 
(concentric  diminution,  H.  W.  Berg)  speaks  for  free  gas  in 
the  peritoneal  cavity, 

Dulness  or  flatness  in  the  loins,  which  shifts  with  a  change 
of  the  patient's  position,  speaks  for  free  exudate  in  the  peri- 
toneal cavity.  (In  percussing  the  loins  for  the  presence  of 
a  free  peritoneal  exudate  we  should  see  to  it  that  the  large 
intestine  is  empty,  lest  fluid  therein  be  mistaken  for  free 
fluid  in  the  peritoneal  cavity.)  Irregular  areas  of  dulness 
or  flatness  speak  for  a  chronic  adhesive  peritonitis  with  or 
without  a  sacculated  fluid  exudate,  for  new-growths,  or  for 
dislocated  viscera.  It  is  to  be  remembered  that  over  col- 
lapsed intestine  the  percussion  note  is  dull. 

Auscultation. — By  auscultation  we  are  enabled  to  elicit: 

(a)  Bruits  over  the  large  vessels;  these  point  to  the  pres- 
ence of  aneurysms  or  to  a  compression  of  the  vessels  by  new- 
growths,  exudates,  or  viscera. 

(6)  Intestinal  bruits  from  abnormal  peristalsis,  and  loud 
noises  made  by  gases  and  fluids  passing  through  a  stenosed 
intestinal  canal. 

(c)  Succussion;  this  results  from  an  admixture  of  gas 
and  fluid  in  a  cavity.  It  is  to  be  heard  over  the  stomach 
and  intestine  and  over  gaseous  abscesses. 


230     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

Probatory  Puncture. — Probatory  puncture  with  a  long, 
fine  needle  is  resorted  to  in  the  differential  diagnosis  of  liver 
and  splenic  abscesses,  retroperitoneal  exudates,  or  neoplasms 
(e.  g.,  of  the  kidney)  or  pelvic  exudates.  In  the  case  of  the 
liver  and  spleen  the  puncture  should  be  made  through  the 
back  or  axillary  region,  or  over  the  convexity  of  the  liver 
from  the  anterior  aspect.  The  point  of  maximum  tender- 
ness should  be  selected  as  the  site  at  which  to  introduce  the 
needle.  The  kindey  is  aspirated  through  the  loin.  The 
material  which  is  obtained  by  aspiration  should  always  be 
examined  microscopically  and  histologically,  and  cultures 
should  be  made  therefrom. 


CHAPTER  XIX. 

DISEASES   OF   THE   ABDOMINAL  WALL   AND    INJURIES 
OF  THE  ABDOMEN. 

TUMORS,  SWELLINGS,  EXUDATES. 

Tumors,  swellings,  and  exudates  in  the  abdominal  wall 
share  its  movement  in  respiration,  which  in  the  dorsal  recum- 
bent position  is  forward  and  backward.  Subcutaneous 
tumors  are  movable  on  the  aponeurotic  layers;  intramural 
tumors  become  more  prominent  on  forcible  contraction  of 
the  abdominal  muscles — e-g-,  during  straining;  and  pro- 
peritoneal  tumors  become  less  prominent  on  such  forcible 
muscular  contraction.  These  general  characteristics  of 
abdominal-wall  tumors  and  swellings  should  be  carefully 
noted  and  remembered,  for  they  will  frequently  stand  us 
in  good  stead  in  differentiating  mural  swellings  and  neo- 
plasms from  intraperitoneal  ones. 

The  failure  of  the  recti  muscles  to  unite  in  the  median 
line  is  recognized  by  a  hernial  protrusion  of  the  abdominal 
viscera  at  the  site  of  the  deficiency.  The  hernia  is  always 
in  the  median  line,  at  the  umbilicus,  in  the  epigastrium,  or 
above  the  symphysis  pubis.  In  the  latter  instance  there  may 
be  an  associated  lack  of  closure  of  the  bladder  and  sym- 
physis pubis,  giving  rise  to  the  malformation  of  ectopia 
vesicje.     (See  also  Ventral  Hernia,  p.  241.) 

Painful,  discolored,  soft,  doughy,  non-fluctuating  swell- 
ings, giving  no  impulse  on  coughing,  unattended  with  fever, 
or  increased  leukocyte  count,  and  coming  on  after  slight  or 
severe  trauma,  or  overexertion  of  the  abdominal  muscles, 
are  characteristic  of  hsematomata  of  the  abdominal  wall. 
Their  occurrence  in  the  course  of  exhausting  diseases  or  in 
marasmic  states  after  very  slight  injuries  to  or  exertions  of 
the  abdominal  muscles  are  no  uncommon  event. 


232     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

The  absence  of  fever  and  leukocytosis,  their  moderate 
tenderness,  and  their  tendency  to  become  smaller  distinguish 
them  from  abscesses;  while  from  neoplasms  they  are  to  be 
differentiated  by  the  facts  that  they  appear  suddenly  and  do 
not  steadily  increase  in  size. 

The  location  of  hernise  in  the  median  line  of  the  abdomen 
or  at  the  inguinal  or  femoral  rings;  their  soft,  elastic,  or 
doughy  character;  their  usual  reducibility  with  impulse  on 
coughing,  and  their  lack  of  pain  or  tenderness  unless  inflamed 
readily  distinguish  the  swellings  to  which  they  give  rise  from 
hsematomata  of  the  abdominal  wall. 


TEARS  AND  RUPTURES  OF  MUSCLES. 

Tears  and  ruptures  of  the  abdominal  muscles  give  rise  to 
hsematomata,  which  in  conjunction  with  the  palpable  hiatus 
between  the  torn  fibres  render  it  easy  to  make  the  diagnosis 
of  this  condition. 


ABSCESSES  OF  ABDOMINAL   WALL. 

Acute. — Acute  abscesses  form  painful,  oedematous,  hot, 
tender,  fluctuating,  circumscribed  or  diffuse  swellings. 
They  are  accompanied  by  a  rise  of  temperature  to  103°  or 
104°,  and  a  leukocytosis  after  three  days  of  from  20,000  to 
30,000.  They  follow  traumata  or  ulceration  and  perfora- 
tion of  the  intestine,  appendix,  caecum,  sigmoid  flexure, 
gall-bladder,  tubes,  ovaries,  or  urinary  bladder,  the  dis- 
eased viscus  having  become  adherent  to  the  abdominal 
parietes  before  the  actual  perforation  occurred;  or  they  are 
secondary  to  disease  of  the  costal  cartilages,  symphysis 
pubis,  or  iliac  bones.  Sometimes  these  mural  abscesses  are 
metastatic  to  suppuration  or  infection  in  distant  organs, 
and  if  no  local  cause  for  their  presence  can  be  ascertained 
the  previous  history  should  be  carefully  sifted  for  such  a 
distant  infection  or  suppuration. 

The  abscesses  may  be  located  superficially  beneath  the 
skin  or  within  or  behind  the  muscular  layer  (mural),  or 


DISEASES  OF   THE  ABDOMINAL   WALL  233 

properitoneally.  The  most  important  of  the  properitoneal 
abscesses  are  the  prevesieah  Where  the  abscess  is  deep 
the  pelvic  organs,  kidneys,  abdominal  viscera,  and  bony 
walls  of  the  abdomen  should  be  carefully  examined  to  ascer- 
tain the  primary  cause  of  the  affection. 

Chronic  or  Latent. — Chronic  or  latent  abscess  and  tuber- 
culous and  actinomycotic  abscesses  occasion  little  or  no 
fever,  and  no  leukocytosis.  Their  differentiation  from 
hsematomata  or  neoplasms  is  not  easy,  and  must  be  made 
from  the  clinical  history,  the  evidence  of  suppuration  or  of 
tuberculosis  or  actinomycosis  in  other  parts  of  the  abdomi- 
nal cavity  or  its  walls,  and  by  exploratory  puncture.  Small 
yellowish  granules,  the  size  of  millet-seed,  which  under  the 
microscope  are  found  to  be  made  up  of  the  ray  fungus,  are 
characteristic  of  actinomycosis.  The  pus  obtained  by 
aspiration  should  always  be  examined  in  smears  and  cul- 
tures. 

NEOPLASMS. 

Benign  tumors  are  circumscribed,  encapsulated,  of  slow 
growth,  painless,  and  cause  no  interference  with  the  general 
health.  Malignant  growths  are  more  diffuse,  infiltrating,  of 
rapid  growth,  somewhat  painful,  and  cause  deterioration  of 
general  health  with  cachexia. 

Neoplasms  may  be  subcutaneous,  intramural,  or  pro- 
peritoneal  in  their  situation  (for  differentiation,  see  remarks 
at  beginning  of  this  chapter). 

Benign  T'amoT&.— Fibromata  molluscmn  are  situated  in 
the  cutaneous  and  subcutaneous  tissues;  they  are  soft,  small, 
tender,  movable,  at  times  pedunculated,  slowly  growing 
tumors. 

The  lifomata  are  situated  chiefly  in  the  flanks  and  in  the 
median  line  of  the  abdomen  above  the  umbilicus.  In  the 
latter  site  they  are  usually  properitoneal  in  origin,  and  push 
forward  between  the  interstices  of  the  linea  alba,  resembling 
in  many  respects  epigastric  hernise,  from  which,  however, 
they  are  to  be  distinguished  by  the  absence  of  gastric  pain 
and  digestive  disturbances. 

The  fibromata  occur  most  frequently  in  women,  developing 
in  the  striae  gravidarum,  but  they  also  form  in  the  cicatricial 


234     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

tissue  left  in  the  abdominal  wall  by  hsematomata  and  mus- 
cular tears.  They  are  located,  as  a  rule,  in  the  median  part 
of  the  abdominal  wall,  closely  attached  to  the  aponeurotic 
structures,  and  form  smooth  or  knotty,  very  hard,  circum- 
scribed, non-tender  tumors  which  have  a  very  slow  growth, 
and  cause  no  disturbance  in  general  health. 

The  absence  of  acute  pain,  temperature  elevations  and 
increased  leukocytosis,  and  of  any  primary  inflammation 
or  disease  of  the  abdominal  or  pelvic  viscera,  or  of  the  bony 
margins  of  the  abdomen,  distinguish  the  fibromata  from 
abscesses.  Properitoneal  fibromata  may  bear  a  strong  re- 
semblance to  intraperitoneal  tumors  of  subjacent  viscera, 
omentum,  etc.  Such  fibromata  are  to  be  differentiated 
from  hepatic  growths  by  their  lack  of  respiratory  mobility, 
and  from  splenic  tumors  by  the  absence  of  the  characteristic 
shape  and  notched  border  of  this  organ.  Omental  growths 
and  intraperitoneal  encapsulated  exudates  which  are  adher- 
ent to  the  abdominal  wall  are  more  difficult  of  differentia- 
tion. Omental  tumors  of  an  inflammatory  nature  are  ten- 
der, painful,  of  more  rapid  growth,  and  are  possibly  attended 
by  fever  and  leukocytosis,  while  those  of  a  malignant  char- 
acter are  of  rapid  growth,  are  frequently  attended  with 
ascites,  and  with  rapid  deterioration  of  the  general  health. 
Inflammatory  exudates  are  of  less  density  than  fibromata, 
and  become  flattened  when  the  patient  assumes  the  recum- 
bent position. 

Mural  fibromata  are  distinguished  from  retroperitoneal 
tumors  by  the  fact  that  they  become  more  prominent  when 
the  stomach  and  colon  are  distended,  whereas  the  retro- 
peritoneal tumors  disappear  under  these  conditions. 

Malignant  Tumors. — Malignant  neoplasms  of  the  ab- 
dominal walls  may  be  located  in  the  skin,  in  which  case 
they  are  the  evidences  of  a  general  sarcomatosis  or  car- 
cinosis or  of  a  melanosarcomatous  degeneration  of  an  old 
naevus.  More  rarely  they  occur  in  the  deeper  layers  as 
primary  sarcoma  or  carcinoma.  At  the  navel  they  may  be 
primary,  but  in  the  other  regions  they  are  usually  metas- 
tatic or  extensions  from  growths  in  the  subjacent  viscera. 

Dermoid  cysts  and  echinococcus  cysts  are  occasionally 
found  on  the  abdominal  wall.    The  former  are  situated  at 


DISEASES  OF   THE  ABDOMINAL   WALL  235 

the  umbilicus.  Should  they  become  inflamed  and  perforate 
into  the  umbilical  area,  there  would  be  a  discharge  of  an 
oily,  cheesy  substance,  and  occasionally  hair.  Echino- 
coccus  cyst  follows  echinococcus  disease  of  the  subjacent 
viscera. 

Growths  involving  the  umbilicus  may  be: 

1.  Navel  granulomata;  these  are  seen  in  the  first  few  weeks 
of  infancy.  They  lack  an  orifice,  and  hence  cannot  be  mis- 
taken for  Dotter's  tract. 

2.  Papillary  fibromata. 

3.  Priiaary  sarcomata  or  carcinomata;  these  form  hard, 
painful,  diffuse  tumors  which  undergo  rapid  ulceration. 


CONTUSIONS  OF  THE  ABDOMEN. 

The  abdominal  wall  alone,  or  an  underlying  viscus  alone, 
or  both  together,  may  be  ruptured  by  a  traumatism.  If  the 
injury  is  limited  to  the  abdominal  wall,  rupture  of  one  or 
more  of  its  constituent  layers  may  result.  If  an  underlying 
viscus  is  ruptured,  the  immediate  symptoms  are  due  to  shock, 
hemorrhage  from  the  ruptured  organ,  and  peritoneal  irrita- 
tion from  the  extravasation  of  blood  or  septic  intestinal  con- 
tents; the  later  symptoms  are  those  of  acute  diffuse  peritonitis, 
the  severity  of  which  depends  on  the  character  of  the  ex- 
travasated  material.  (See  Perforations  into  the  Peritoneal 
Cavity,  p.  274.)  Immediately  after  the  injury  the  patient  is 
in  a  shocked  condition,  with  pallid,  cold  skin;  rapid,  feeble 
pulse;  slow,  shallow  respiration,  and  subnormal  temperature. 
If  there  is  a  profuse  hemorrhage  into  the  peritoneal  cavity 
— e.  g.,  from  rupture  of  liver,  spleen,  or  bloodvessels  of  large 
size,  or  extensive  extravasation  of  septic  matter — stimulation 
and  the  application  of  heat  do  not  succeed  in  reviving  the 
patient  from  this  shocked  condition;  the  pulse  becomes 
progressively  more  rapid  and  feeble,  and  death  ensues.  With 
slow  hemorrhage  or  gradual  extravasation  of  septic  material, 
the  patient  usually  reacts  from  shock  and  within  the  next 
few  hours  manifests  the  following  symptoms:  The  pulse 
rate  gradually  but  continuously  rises  in  rapidity  (to  90, 
to  100,  to  110,  to  120);  the  temperature  rises  to  normal; 


236     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

vomiting  may  or  may  not  occur.  The  abdominal  wall 
becomes  rigid,  and  does  not  move  with  respiration.  There  is 
pain  and  tenderness  at  the  site  of  the  contusion;  possibly  a 
local  area  of  dulness  corresponding  to  extravasated  blood  or 
intestinal  contents.  If  the  condition  is  unrelieved,  death  from 
continued  hemorrhage  may  occur,  or  diffuse  or  circumscribed 
peritonitis  develop.  If  no  infected  material  is  extravasated 
into  the  peritoneal  cavity,  or  if  the  hemorrhage  ceases  and 
no  secondary  infection  of  the  blood  clot  takes  place,  an 
aseptic  peritonitis  develops  from  which  recovery  usually 
occurs.     (For  symptoms  of  peritonitis,  see  p.  248.) 

Visceral  involvement  with  an  abdominal  contusion  is  recog- 
nized during  the  first  few  hours  after  the  injury  from  abdom- 
inal rigidity  and  increasing  pulse  rate.  The  presence  of 
these  two  signs  should  always  prompt  immediate  operative 
exploration.  If  a  hollow  viscus  has  been  ruptured,  the 
concentric  obscuration  of  liver  and  splenic  dulness  is  impor- 
tant evidence.  When  a  diffuse  or  circumscribed  peritonitis 
has  developed  the  diagnosis  becomes  very  simple.  In  con- 
nection with  abdominal  injuries  we  should  remember  that 
even  without  visceral  lesions  death  from  reflex  shock  may 
result. 

OPEN  WOUNDS  OF  THE  ABDOMEN. 

Non-penetrating  wounds  of  the  abdominal  walls  have 
no  especial  significance.  Penetrating  wounds  may  or  may 
not  involve  the  abdominal  viscera.  In  all  cases,  just  as  with 
contusions,  there  is  shock  and  hemorrhage  of  varying  degree. 
Penetrating  wounds  without  visceral  involvement  may  give 
rise  to  local  or  diffuse  peritonitis.  With  visceral  involvement 
the  early  and  late  symptoms  resemble  those  of  contusions 
with  visceral  rupture.  The  diagnosis  of  visceral  complica- 
tion in  the  early  stages  is  made  from  the  abdominal  rigidity 
and  the  increasing  pulse  rate,  with  or  without  concentric 
obliteration  of  liver  and  splenic  dulness.  In  the  late  stages 
the  presence  of  a  diffuse  peritonitis  makes  the  diagnosis 
easy. 


CHAPTER  XX. 
HERNIA. 


Generally  speaking,  a  hernia  may  be  defined  as  a 
swelling  which  appears  on  assuming  the  erect  position, 
grows  larger  on  straining,  gives  an  impulse  on  coughing, 


Fig.  119 


Oblique  inguinal  hernia. 

and  is  reducible.  These  general  characteristics  enable  one 
to  recognize  an  uncomplicated  hernial  protrusion,  but  one 
should  never  rest  satisfied  with  this;  he  should  endeavor  to 


238     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

ascertain  the  definite  variety  of  the  hernia,  the  nature  of  its 
contents,  and  the  presence  of  any  compHcations. 


VARIETIES  OF  HERNIA. 

In  inguinal  hernia  the  hernial  orifice  is  above  Poupart's 
Hgament,  the  swelhng  is  internal  to  and  covers  the  pubic 
spine,  the  canal  is  oblique  or  straight,  and  the  neck  in  the 
oblique  variety  is  just  external  to  the  deep  epigastric  vessels 
and  internal  to  them  in  the  direct  variety.    The  latter  hernise 

Fig.  120 


Femoral  hernia.    (Von  Bergmann.) 

lie  internal  to  the  spermatic  cord,   are  usually  small,   of 
rounded  shape,  and  rarely  become  scrotal. 

Properitoneal  and  superficial  inguinal  hernice  are  usually 
associated  with  an  undescended  testicle  of  the  corresponding 
side.  In  the  former  the  testicle  is  just  outside  the  internal 
inguinal  ring,  and  in  the  latter  just  outside  of  the  external 
ring.  In  either  case  the  corresponding  testicle  is  absent 
from  the  scrotum.  A  properitoneal  hernia  forms  an  elongated, 
rounded  tumor,  lying  just  above  Poupart's  ligament,  external 
to  the  pubic  spine.     It  does  not  occupy  the  inguinal  canal 


HERNIA 


239 


except  when  the  sac  is  bilocular,  in  which  case  one  division 
thereof  extends  into  it.  In  the  bilocular  variety  the  hernial 
contents  often  reduce  from  the  lower  into  the  upper  division 
of  the  sac.  The  bilocular  condition  should  always  be 
suspected  in  cases  of  strangulated  properitoneal  hernia 
when  the  symptoms  of  strangulation  persist  after  apparently 
successful  reduction  by  taxis. 

A  superficial  inguinal  hernia  lies  just  beneath  the  skin 
of  the  inguinal  region.     When  it  becomes  strangulated  it 


Fig. 121 


Hernia  of  cord.    (Von  Bergmann.) 


must  be  carefully  differentiated  from  inflamed  ectopic  tes- 
ticle.    (See  p.  243.) 

In  femoral  hernice  the  orifice  lies  beloiu  Poupart's  ligament, 
external  to  the  pubic  spine,  and  the  neck  lies  internal  to  the 
femoral  vessels. 

Obturator  hernice  appear  beneath  the  horizontal  ramus  of 
the  pubis,  internal  to  the  femoral  vessels,  and  are  covered 
by  the  pectineus  and  adductor  longus  muscles.    They  form 


240     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

small  tumors  which  press  upon  the  obturator  nerves,  causing 
thereby  pain  along  the  inner  side  of  the  thigh,  in  the  hip 
and  knee-joints,  and  paresis  of  the  adductor  muscles.  When 
their  existence  is  suspected  an  attempt  should  be  made 
to  palpate  through  the  rectum  or  vagina,  the  internal  hernial 
orifice  at  the  obturator  foramen.    By  flexing  and  adducting 


Fig.  122 


Large  irreducible  umbilical  hernia. 

the  limb,  one  is  sometimes  enabled  to  palpate  the  hernia 
beneath  the  adductor  longus  muscle,  or  appreciate  the 
bulging  of  the  hernial  tumor  with  the  naked  eye.  The 
diagnosis  is  especially  important  when  the  hernia  becomes 
strangulated,  and  one  should  never  forget  to  look  for  an 
obturator  hernia  when  there  are  symptoms  of  acute  intestinal 
obstruction  that  are  not  to  be  accounted  for  by  some  other 


HERNIA 


241 


cause.  Pelvic  exudates  and  neuritis  of  the  obturator  nerve 
may  simulate  this  form  of  hernia.  Vaginal  examination 
in  the  former  and  the  improvement  of  the  symptoms  by 
treatment  in  the  latter  should  establish  the  correct  diagnosis. 
Hernias  of  the  umbilical  cord  are  noticed  at  the  birth  of 
the  child.  These  infants  usually  die  shortly  after  birth, 
from  sepsis  due  to  the  sloughing  of   the  hernial  sac  and  its 

Fig.  123 


Large  irreducible  ventral  hernia. 


contents.  Occasionally  when  the  hernia  is  small  and  contains 
only  a  single  loop  of  intestine,  the  child  survives  the  slough- 
ing and  retains  an  intestinal  fistula  at  the  umbilicus,  which 
must  not  be  confounded  with  a  patent  omphalomesenteric 
duct  (Dotter's  fistula).  These  hernise  are  sometimes  very 
large,  as  when  the  liver  occupies  the  hernial  sac;  their  cover- 
ing is  derived  from  the  amnion,  over  which  are  spread  out 
the  umbilical  vessels. 

16 


242     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

Hernice  at  the  umhilicus  occur  in  children  and  in  adults. 
In  the  former  they  form  small  tumors  with  the  navel  on 
their  under  side.  In  the  latter  they  usually  form  large  tumors 
with  diverticula  going  off  from  the  main  sac ;  they  frequently 
become  irreducible. 

Ventral  hernice  develop  in  anatomically  weak  places  of 
the  abdominal  wall — e.  g.,  in  the  linea  alba  (owing  to  a 

Fig.  124 


Congenital  lateral  ventral  hernia.    (Wyss.) 


diastasis  of  the  recti  muscles),  in  the  triangle  of  Petit,  and  in 
the  linea  semilunaris. 

Diastasis  of  the  recti  muscles  permits  of  a  protrusion  of 
the  abdominal  contents  during  straining.  There  is  no  dis- 
tinct sac  and  no  hernial  orifice. 

Epigastric  hernias  develop  in  the  linea  alba  of  the  epigas- 
trium. They  are  usually  small,  and  associated  with  pro- 
peritoneal  lipomata.  They  occasion  continuous  or  colicky 
gastric  pains  and  disturbances  of  gastric  digestion,  simulat- 


HERNIA  243 

ing  thereby  chronic  diseases  of  the  stomach;  the  differentia- 
tion from  the  latter  is  to  be  made  by  an  examination  of  the 
gastric  contents,  by  careful  observation,  and  by  the  presence 
of  the  hernial  orifice. 

HernioB  at  the  linea  semilunaris  are  usually  found  in 
elderly  or  feeble  subjects,  and  are  usually  properitoneal. 

Hernice  through  the  triangle  of  Petit  (which  is  located 
between  the  twelfth  rib  and  iliac  crest,  the  external  oblique 
origin  and  the  outer  border  of  the  latissimus  dorsi)  follow 
trauma  or  muscular  weakness  or  operations  in  this  region. 
They  should  be  distinguished  from  the  outward  bulging 
which  is  due  to  a  paretic  condition  of  the  abdominal  muscles. 
These  latter  are  not  true  hernise;  they  have  neither  hernial 
orifice,  nor  sac,  nor  contents. 

Hernice  after  laparotomy  and  trauma  are  large  or  small; 
they  are  apt  to  be  irreducible  and  do  not  often  become 
strangulated. 

CONTENTS  OF  HERNIA. 

The  contents  of  the  hernial  sac  may  be  intestine,  omentum, 
testicle,  ovary,  appendix,  bladder,  or  other  intraperitoneal 
viscus,  and  occasionally  foreign  bodies  derived  from  these 
viscera — e.  g.,  vesical  stone,  round  worms,  etc. 

Intestines  are  recognized  by  their  elastic  feel,  their  tym- 
panitic percussion  note,  and  by  the  gurgling  sound  which 
is  heard  on  their  reduction  into  the  abdominal  cavity. 

Omentum  is  recognized  by  its  doughy  feel,  dull  percus- 
sion note,  and  the  absence  of  a  gurgling  sound  on  reduction. 

The  ovary  and  tube  are  recognized  by  their  swelling  at 
the  menstrual  periods  and  by  the  peculiar  ovarian  sensation 
which  is  felt  by  the  patient  when  the  organ  is  squeezed.  By 
vaginal  examination  the  broad  ligament  and  appendages  of 
the  corresponding  side  can  be  traced  into  the  hernial  ring. 

The  testicle  is  recognized  by  its  shape,  and  the  peculiar 
testicular  sensation  which  is  experienced  when  the  organ 
is  squeezed.  The  absence  of  this  organ  from  the  scrotum 
is  additional  evidence. 

The  bladder  is  suspected  when  there  is  vesical  tenesmus 
and  irritation;  the  suspicion  can  be  verified  by  cystoscopic 


244     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

examination,  by  distention  of  the  bladder  (the  hernia  swell- 
ing as  the  fluid  is  injected),  and  by  passing  a  sound  into 
the  bladder  (if  the  bladder  is  in  the  hernial  sac  the  sound 
can  sometimes  be  made  to  enter  the  hernial  canal). 

The  appendix  can  be  palpated  as  a  long,  narrow,  cylin- 
drical body. 

The  liver  and  spleen  are  recognized  by  their  shape  and 
consistency. 

The  stomach  is  suspected  if  there  is  marked  gastric  pain 
and  vomiting. 

These  viscera  while  in  the  hernial  sac  may  become  dis- 
eased; thus  in  the  Fallopian  tube  a  pyosalpinx  or  hemato- 
salpinx or  extrauterine  pregnancy  may  form;  in  the  ovary, 
an  ovarian  abscess  or  cyst;  in  the  appendix,  an  acute  inflam- 
mation. From  the  physical  examination  as  outlined  above 
the  organ  which  occupies  the  hernial  sac  is  to  be  recognized, 
and  from  the  clinical  symptoms  the  pathological  process 
which  is  going  on  in  the  affected  organ  is  to  be  diagnosed. 


DIAGNOSIS  OF  COMPLICATIONS  OF  HERNIA. 

Irreducibility  is  characterized  by  an  inability  to  replace 
the  hernial  contents  within  the  abdomen.  If  there  is  no 
coexisting  incarceration  or  strangulation  of  the  hernial 
contents  there  will  be  no  other  changes  in  the  hernia.  Its 
impulse  on  coughing  persists. 

Inflammation  is  evidenced  by  severe,  continuous,  or  colicky 
pain,  by  vomiting,  and  by  constipation;  the  hernia  becoming 
larger  in  size,  usually  irreducible,  and  affording  no  impulse 
on  coughing;  the  overlying  skin  is  red  or  bluish  or  cedema- 
tous;  the  sac  is  tense,  and  there  may  be  peritoneal  crepita- 
tion over  it.  The  vomiting  is  especially  marked  if  there  is 
peritonitis;  the  constipation  is  never  absolute,  for  even 
with  peritoneal  involvement  foul-smelling  gases  may  be 
passed  per  rectum. 

Inflammation  results  from  trauma  to  or  strangulation 
or  disease  of  the  hernial  contents,  and  as  a  result  thereof 
perforation  of  the  prolapsed  viscus  may  result.  The  latter 
is  attended  by  sudden  severe  pain  in  the  hernia  and  possibly 


HERNIA  245 

by  collapse,  by  gaseous  crackling,  and  in  some  instances  by 
abscess  formation  in  the  sac.  When  the  latter  occurs  the 
hernia  becomes  hard  and  very  tender. 

Obstruction  results  from  stasis  of  the  material  contained 
within  the  prolapsed  intestine.  It  is  especially  apt  to  occur 
in  large  irreducible  hernise  and  in  old  subjects.  There  is 
in  simple  obstruction  no  compression  or  strangulation  of  the 
bowel.  It  is  evidenced  by  constipation,  nausea,  sometimes 
by  vomiting  and  by  severe  colicky  pain.  The  constipation 
is  never  absolute,  as  foul-smelling  gases  are  passed  by 
rectum.  This  condition  is  distinguished  from  strangulation 
by  its  gradual  onset,  by  the  absence  of  tension  within  the 
sac,  by  the  presence  of  soft,  doughy,  indentable  (fecal) 
masses  in  the  prolapsed  bowel,  and  by  the  persistence  of 
the  impulse  on  coughing  or  straining.  But  such  cases 
should  always  be  carefully  observed,  and  until  the  bowels 
move  satisfactorily  the  possibility  of  a  strangulation  being 
present  should  never  be  dismissed.  One  successful  enema  is 
no  proof  of  the  patency  of  the  lumen  of  the  bowel;  repeated 
successful  enemata  point  to  the  absence  of  strangulation. 

Torsion  of  the  contents  gives  the  same  signs  as  inflamma- 
tion or  strangulation,  though  usually  of  a  less  intense  grade. 
It  should  be  suspected  in  cases  of  long-standing  omental 
hernia  in  which  there  is  a  mass  in  the  abdomen  that  reaches 
down  into  the  hernial  sac. 

Strangulation  occurring  in  a  previously  reducible  hernia 
results  in  its  becoming  at  once  irreducible.  The  hernia, 
whether  previously  reducible  or  irreducible,  increases  in 
size,  becomes  tender  and  tense,  and  loses  its  impulse.  The 
patient  vomits,  at  first  the  contents  of  the  stomach,  and 
later  on  the  contents  of  the  upper  and  lower  bowel  (biliary 
and  fecal  material),  the  abdomen  becomes  distended,  the 
urine  diminished  in  amount,  and  the  bowels  absolutely 
constipated.  One  or  two  evacuations  from  the  bowel 
below  the  site  of  strangulation  may  take  place  after  the 
occurrence  of  this  complication,  and  in  those  cases  in  which 
only  a  portion  of  the  wall  of  the  intestine  is  strangulated, 
gases  and  bloody,  diarrhoeal  mucus  with  fecal  particles 
may  be  passed  by  the  rectum.  There  is  severe  pain  in  the 
hernia  and  the  patient  is  more  or  less  prostrated.     If  the 


246     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

affected  loop  of  intestine  perforates,  there  is  a  sudden  tear- 
ing pain  in  the  hernia  with  diminution  of  its  tension,  and 
temporary  reUef  of  the  previous  pain,  but  the  patient  be- 
comes more  or  less  deeply  collapsed.  Gangrene  of  the 
strangulated  hernial  contents  is  attended  by  temporary  relief 
of  pain  and  tension,  but  is  followed  by  peritonitis. 

Obstructed,  inflamed,  and  strangulated  hernise  may  be 
confounded  with  an  inflamed,  undescended  testicle,  or  with 
inflamed  inguinal  and  femoral  glands.  With  an  inflamed, 
undescended  testicle  this  organ  is  not  in  the  scrotum;  the 
constipation  is  not  absolute,  and  the  vomiting  is  not  inces- 
sant nor  fecal.  With  inflamed  glands  there  is  no  previous 
history  of  hernia,  there  is  a  primary  focus  of  infection  on 
the  leg  or  thigh  or  genitals,  the  constipation  is  not  absolute, 
nor  is  the  vomiting  so  marked.  In  all  of  these  cases  careful 
observation  and  repeated  examinations  are  necessary,  and 
should  doubt  exist  it  is  better  to  operate  than  risk  the  dan- 
gers of  an  unrelieved  strangulation. 


DIFFERENTIAL  DIAGNOSIS  OF  THE  SPECIAL  HERNIA. 

Inguinal  Hernise.  Congenital. — Congenital  inguinal  her- 
nise  date  from  early  infancy.  They  are  scrotal  from  the 
verv  beginning,  have  an  elongated,  cylindrical  form,  are 
closely  adherent  to  the  spermatic  cord,  and  are  frequently 
associated  with  an  undescended  testicle  and  hydrocele  of 
the  cord  and  tunica  vaginalis.  If  the  testicle  is  in  the  scrotum 
the  hernia  lies  in  front  of  it.  In  the  funicular  variety  the 
testis  lies  below  the  hernia. 

Acquired. — Acquired  inguinal  hernia  may  be  entirely 
within  the  inguinal  canal  (bubonocele),  or  they  may  descend 
into  the  scrotum,  in  which  case  the  testis  is  always  below 
the  hernia. 

A  bubonocele  or  incomplete  hernia  is  distinguished  from 
an  undescended  testicle  by  the  presence  of  the  testicle  in 
the  scrotum,  and  by  the  absence  of  the  pecuUar  testicular 
sensation  when  the  swelling  is  compressed.  An  inflamed, 
undescended  testicle  is  to  be  especially  differentiated  from 
a  strangulated  hernia. 


HERNIA  247 

Hydrocele  of  the  cord  and  of  the  tunica  vaginaHs  are 
distinguished  from  this  variety  of  hernia  by  their  trans- 
lucency,  duhiess  to  percussion,  fluctuation,  and  slow  or 
entire  absence  of  reducibility.  If  they  are  reducible  there  is 
no  gurgle.  A  congenital  hydrocele  reduces  into  the  abdo- 
men and  is,  as  a  rule,  associated  with  a  hernia.  A  bilocular 
hydrocele  reduces  into  the  iliac  fossa,  where  it  forms  a  dis- 
tinct tumor,  the  tension  of  which  rises  when  pressure  is  made 
upon  the  scrotal  portion. 

A  hydrocele  of  the  tunica  vaginalis  always  lies  in  front 
of  the  testicle. 

A  varicocele  feels  like  a  mass  of  earthworms;  it  gives  no 
impulse  on  coughing;  it  does  not  reduce  with  a  gurgle  and 
when  it  is  reduced  it  returns  even  though  pressure  is  made 
over  the  external  inguinal  ring.  The  swelling  enlarges  from 
below  upward. 

A  lipoma  of  the  cord  is  soft  and  lobulated;  it  does  not 
reduce  with  a  gurgle,  it  gives  no  impulse  on  coughing,  and 
unless  it  is  very  large  it  causes  no  pain  or  dragging  sensation. 

Femoral  herniee  are  distinguished  from  enlarged  femoral 
glands  by  their  reducibility  with  a  gurgle  and  their  impulse 
on  coughing.  A  varicose  internal  saphenous  vein  is  differ- 
entiated from  a  femoral  hernia  by  the  absence  of  all  the 
physical  signs  of  a  hernia  and  by  its  reappearing  from 
below  upward,  even  though  pressure  is  made  over  the 
saphenous   opening. 

Before  closing  this  chapter  let  me  advise  all  beginners 
to  carefully  examine  their  patients  who  complain  of  intes- 
tinal colic  or  of  dragging  pains  in  the  abdomen,  or  of  gastric 
pain  and  vomiting  for  a  hernia.  A  radical  operation  for 
hernia  or  a  well-fitting  truss  will  often  put  an  end  to  the 
obscure  intestinal  or  gastric  pains,  that  may  have  been 
ascribed  to  nervous  or  functional  or  more  serious  organic 
lesions. 


CHAPTER  XXL 

DISEASES    OF    THE    PERITONEUM.       ASCITES.       SUB- 
PHRENIC   ABSCESS. 

ACUTE  INFECTIOUS  PERITONITIS. 

The  clinical  manifestations  of  acute  circumscribed  and 
diffuse  infectious  peritonitis  are  so  characteristic  that  even 
beginners  in  diagnosis  will  have  no  difficulty  in  recognizing 
these  conditions. 

With  acute  diffuse  peritonitis  the  patient  looks  sick, 
anxious,  and  restless;  he  lies  on  his  back  with  his  thighs  and 
legs  flexed,  and  in  the  later  stages  of  the  disease  he  is 
cyanosed,  the  features  having  a  pinched  expression  (the 
facies  hippocratica).  The  sensorium  is  clear  or  somewhat 
excited  and  elated,  the  skin  is  cool  and  sometimes  clammy, 
the  breathing  is  thoracic  and  rapid,  the  pulse  rate  is  rapid 
and  increases  in  rapidity,  the  temperature  is  usually  elevated, 
the  bowels  are  constipated,  there  is  incessant  vomiting  of 
gastric  and  intestinal  contents,  and  a  markedly  diminished 
excretion  of  urine,  which  contains  indican.  The  leuko- 
cytes may  be  normal  or  increased  to  15,000  or  20,000  or 
over.  The  number  of  leukocytes  is,  however,  of  no  diag- 
nostic value;  high  counts  seem  to  be  present  in  the  less 
severely  septic  cases. 

The  abdomen  is  distended  and  painful;  its  wall  does  not 
move  with  respiration,  and  is  rigid,  hard,  and  tender  to  the 
slightest  touch;  there  is  a  gradually  increasing  movable 
dulness  in  the  flanks.  (In  percussion  of  the  abdomen  for 
detecting  an  exudate  it  is  necessary  to  first  of  all  empty  the 
large  bowel,  for  fluid  in  a  distended  colon  will  often  give  a 
shifting  dulness  in  the  flanks.) 


DISEASES  OF  THE  PERITONEUM  249 


PERITONEAL  SEPTIC-fflMIA. 

With  peritoneal  septicemia  the  general  symptoms  of 
toxaemia  and  vagus  paralysis  are  much  more  marked  than 
the  abdominal  ones.  The  patients  are  collapsed,  the  pulse 
is  very  rapid  and  feeble,  the  respirations  rapid,  and  the 
temperature  not  much  elevated.  The  sensorium  is  clear, 
and  there  is  a  feeling  of  elation.  The  leukocyte  count  is 
not  much  higher  than  the  normal. 

(For  circumscribed  and  diffuse  peritonitis  following  per- 
foration of  a  hollow  viscus  or  abscess  or  infected  neoplasm, 
see  p.  274.) 


CIRCUMSCRIBED  PERITONITIS. 

With  circumscribed  peritonitis  the  general  manifestations 
are  much  less  severe  than  in  the  preceding.  The  facial  ex- 
pression, color,  and  type  of  respiration  are  not  much  altered. 
The  pulse  rate  is  either  normal  or  only  slightly  elevated;  the 
temperature  varies  from  moderate  to  considerable  elevations. 
With  an  encapsulated  purulent  exudate  under  considerable 
tension,  the  temperature  will  be  quite  high  and  the  leukocytes 
increased  to  20,000  or  more;  but  when  the  tension  is  low 
even  purulent  exudates  do  not  occasion  a  very  high 
temperature. 

At  the  outset  there  may  be  general  abdominal  pain, 
vomiting,  intestinal  distention,  and  constipation.  These 
disappear  after  twenty-four  or  forty-eight  hours,  and  the 
pain  becomes  localized  to  the  region  occupied  by  the  primary 
focus  of  the  disease.  This  area  becomes  tender,  the  abdom- 
inal wall  over  it  is  rigid,  and  the  intestine  at  this  site  may 
be  distended. 

Such  clinical  pictures  will  very  rarely  leave  any  doubt  as 
to  the  nature  of  the  disease.  But  our  efforts  do  not  and 
should  not  end  with  having  established  the  presence  of  a 
peritonitis.  This  malady  is  always  secondary  to  injury  or 
disease  of  some  one  or  other  of  the  intra-abdominal  organs 
or  of  the  abdominal  wall,  or  of  a  constitutional  disease  like 


250     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

pneumonia,  etc.,  and  if  we  would  be  successful  in  our  treat- 
ment of  the  peritonitis  we  must  first  of  all  ascertain  and 
remove  its  cause.  The  primary  focus  of  disease  and  its 
character  will  often  be  ascertained  from  the  previous  history, 
for  the  diseased  organ  has  usually  manifested  its  own  train 
of  symptoms  for  some  time  prior  to  the  onset  of  the  peritonitis 
— e.  g.,  a  diseased  appendix,  or  a  gastric  or  duodenal  ulcer, 
or  cholelithiasis,  etc.  The  point  of  origin  of  the  pain  and 
the  site  of  its  greatest  intensity  will  frequently  guide  us  to 
the  diseased  organ  that  has  provoked  the  peritonitis. 

At  the  outset  of  the  peritonitis  it  is  impossible  to  differ- 
entiate the  diffuse  from  the  circumscribed  forms,  or  to 
predict  that  in  a  certain  case  the  peritonitis  will  remain 
circumscribed.  A  rising  pulse  rate,  anxious  expression, 
and  increasing  abdominal  rigidity  speak  for  advancing 
peritonitis   and  urgently  indicate  operative  interference. 

Stone  colic  may  simulate  peritonitis.  In  both  there  is 
marked  abdominal  pain,  vomiting,  constipation,  and  dis- 
tention. In  stone  colic  the  pain  is  most  intense  at  the  site 
of  impaction  of  the  stone,  and  radiates  from  this  point  in  a 
direction  that  is  characteristic  to  the  organ  in  which  the 
calculus  is  contained.  There  is  no  general  abdominal  rigidity 
and  no  pain  or  tenderness. 

Acute  enteritis  is  to  be  differentiated  from  peritonitis  by 
the  absence  of  abdominal  rigidity,  thoracic  breathing,  and 
increasing  rapidity  of  the  pulse. 

hitestinal  obstruction  differs  from  peritonitis  in  that  it 
is  not  attended  with  constitutional  symptoms  during  the 
early  stages.  Furthermore,  in  obstruction  the  pain  comes 
on  in  attacks;  there  is  at  the  outset  increased  peristalsis, 
and  on  palpation  of  the  abdomen  a  fixed  loop  of  bowel 
can  often  be  detected;  the  abdominal  wall  is  not  rigid  and 
tender,  the  distention  is  at  first  limited  to  the  site  of  obstruc- 
tion, and  the  breathing  is  not  thoracic.  In  obstruction  the 
constipation  is  absolute,  whereas  in  peritonitis  gas  and 
some  fecal  matter  may  be  passed.  When  peritonitis  super- 
venes upon  the  intestinal  obstruction  these  differences 
gradually  disappear. 


DISEASES  OF   THE  PERITONEUM  251 


CHRONIC  ADHESIVE  PERITONITIS. 

The  intraperitoneal  adhesions  or  bands,  which  result 
from  a  chronic  adhesive  peritonitis,  may  occasion  com- 
pression or  kinking  or  strangulation  or  contraction  of  the 
mesentery  of  the  hollow  intraperitoneal  viscera,  with  con- 
sequent stenosis  or  complete  obstruction  of  their  lumina 
or  strangulation  of  their  nutrient  vessels. 

The  stenotic  symptoms  (see  p.  250)  are  of  gradual  onset 
and  development,  and  are  distinguished  from  those  due 
to  a  malignant  neoplasm  by  the  absence  of  a  tumor  and 
cachexia.  In  the  case  of  the  pylorus,  the  presence  of  free 
hydrochloric  acid  and  ferments  in  the  gastric  juice  and 
the  absence  of  lactic  acid  therefrom  are  additional  data 
to  distinguish  a  pyloric  stenosis  produced  by  adhesions  or 
bands  from  that  due  to  a  cancer. 

The  onset  and  course  of  acute  intestinal  obstruction  or 
of  volvulus  due  to  such  adhesions  are  similar  to  those  which 
attend  these  conditions  when  arising  from  other  causes. 

The  dependence  of  these  conditions  upon  peritoneal  adhe- 
sions can  be  established  prior  to  operation  only  if  the  patient 
gives  a  history  of  previous  inflammation  of  an  intraperitoneal 
organ — e.  g.,  of  the  appendix,  gall-bladder,  genital  organs  in 
the  female,  etc. — or  a  history  of  an  abdominal  injury  or 
operation,  of  coprostasis,  or  of  syphilis. 


TUBERCULOUS  PERITONITIS. 

Tuberculosis  of  the  peritoneum  may  manifest  itself  by  the 
symptoms  of  chronic  intestinal  stenosis,  or  by  the  presence 
of  nodular  masses  in  the  abdomen,  or  by  the  presence  of  a 
free  or  encapsulated  exudate  in  the  peritoneal  cavity,  or  by 
combinations  of  these.  Patients  suffering  with  this  malady 
usually  have  some  other  focus  of  tuberculous  disease — e.  g., 
in  the  genital  organs,  lungs,  intestines,  lymphatic  glands, 
bones,  or  joints.  They  become  emaciated  and  weak,  have 
an  irregular,  moderate  fever,  and  suffer  from  gastrointestinal 
disturbances. 


252     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

The  nodular  masses  are  few  or  many,  soft  or  hard,  large 
or  small.  Free  exudates  give  rise  to  shifting  dulness  in  the 
flanks,  distention  of  the  abdomen,  protrusion  of  the  umbili- 
cus, and  bulging  of  the  flanks.  Encapsulated  exudates 
occasion  irregular  areas  of  dulness  in  the  abdomen,  which 
change  their  size  and  position  from  day  to  day;  they  may 
resemble  intra-abdominal  cystic  tumors,  but  they  are  distin- 
guished from  them  by  their  irregularity,  their  change  in  size 
and  position  from  time  to  time,  their  multiplicity,  their 
intimate  adherence  to  the  abdominal  wall,  intestines,  and 
omentum,  their  flattened  shape  when  the  patient  assumes 
the  recumbent  position,  and  by  the  presence  of  tuberculous 
foci  in  other  organs. 

The  nodular  masses  may  be  mistaken  for  malignant  disease 
of  the  peritoneum;  but  the  latter  is  always  secondary  to 
carcinoma  of  other  abdominal  organs,  occurs  in  much  older 
subjects,  and  causes  marked  cachexia.  The  free  peritoneal 
exudate  may  be  thought  to  be  due  to  cirrhosis  of  the  liver, 
but  this  condition  is  found  chiefly  in  alcoholics  and  in 
syphilitics;  with  it  the  liver  is  knobby,  irregular,  and  usually 
small,  and  there  are  other  evidences  of  portal  obstruction — 
e.  g.,  hsematemesis,  melsena,  hemorrhoids,  enlarged  spleen, 
etc, 

ASCITES. 

An  accumulation  of  fluid  in  the  peritoneal  cavity  is  mani- 
fested by  a  protruding  umbilicus,  a  distended  condition  of 
the  abdomen,  which  becomes  flattened  in  the  middle  and 
ballooned  out  on  the  sides  when  the  patient  assumes  the 
dorsal  recumbent  position,  which  is  tympanitic  to  percus- 
sion in  the  centre  and  above  and  flat  in  the  flanks,  the  latter 
being  replaced  by  tympanitic  resonance  when  the  patient's 
position  is  changed  to  one  or  the  other  side  (shifting  flatness), 
and  which  gives  the  sensation  of  a  fluid  wave  when  it  is  lightly 
tapped.  The  shifting  dulness  in  the  flanks  is  naturally  one 
of  the  first  indications  of  such  a  fluid  collection,  and  as  this 
is  very  strongly  simulated  by  fluid  accumulations  in  the  large 
intestines,  we  must  see  to  it  that  the  bowel  is  emptied  before 
we  interpret  this  physical  sign  as  due  to  fluid  within  the 
peritoneal  cavity. 


DISEASES  OF   THE  PERITONEUM  253 

Purulent  and  hemorrhagic  fluid  exudates  are  rarely  suf- 
ficient in  amount  to  distend  the  abdomen;  their  presence 
is  usually  determined  from  the  shifting  dulness  in  the  flanks. 

Serous  or  ascitic  exudates  due  to  disturbances  in  the 
general  circulation  from  pulmonary,  cardiac,  or  nephritic 
disease,  or  to  disturbances  in  the  portal  circulation  from 
portal  thrombosis,  liver  cirrhosis,  or  diseases  of  the  spleen. 

Fig.  125 


Shape  of  the  abdomen  in  ascites.    Note  the  protruding  umbilicus,  the  bulging  flanks, 
and  the  barrel  shape. 

frequently  reach  large  amounts.  The  fluid  is  usually  clear, 
of  a  yellowish  color,  1012  specific  gravity,  alkaline  in  reac- 
tion, coagulates  slightly  on  standing,  and  is  rich  in  proteids. 
Microscopically  it  contains  but  few  formed  elements.^  The 
admixture  of  blood  points  to  carcinoma,  tuberculosis,  or 
traumatism;  a  milky  admixture,  chylous  ascites,  points  to 
obstruction  of  the  chyle-ducts  or  to  obstruction  of  the  thoracic 
ducts  by  tumors,  entozoa,  or  thrombosis. 

1  These  characteristics  distinguish  it  from  inflammatory  exudates  and  cystic  con- 
tents. Peritoneal  exudates  have  a  specific  gravity  of  1028,  coagulate  on  standing,  and 
contain  many  formed  elements.  Ovarian  cystic  fluid  does  not  coagulate  on  standing 
and  echinococcus  cystic  fluid  is  poor  in  proteids. 


254     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 


SUBPHRENIC  ABSCESS. 


The  presence  of  pus,  or  of  gas^  and  pus,  in  the  subphrenic 
spaces,  the  latter  condition  constituting  the  pyopneumo- 
thoracis  subphrenicus  of  Leyden,  is  readily  determined  from 
the  constitutional  evidences  that  always  attend  pus  forma- 
tion, and  from  the  physical  signs  which  an  abscess  in  these 


Fig. 126 


Left  pyopneumothorax.    Note  the  displacement  of  the  heart  to  the  right,  the  com- 
pression of  the  left  lung,  and  the  depression  of  the  diaphragm.    (Maydl.) 

regions  affords.  Our  diagnostic  efforts  should  not,  how- 
ever, end  with  this  determination.  These  abscesses  are 
almost  invariably  secondary  to  suppuration  or  ulceration 
within  the  abdominal  or  thoracic  cavities,  and  our  efforts 
should  be  directed  to  ascertaining  the  location  and  character 
of  the  primary  disease.    This  latter  is  not  so  easy,  but  if  we 

1  The  gas  is  derived  from  a  ruptured  hollow  viscus  or  from  gas-forming  bacteria. 


DISEASES  OF   THE  PERITONEUM 


255 


probe  carefully  into  the  patient's  history  prior  to  the  advent 
of  the  subphrenic  suppuration,  study  the  character  of  its 
onset,  and  examine  the  pus,  both  in  smears  and  by  culture, 
we  shall  in  most  instances  be  able  to  arrive  at  a  correct 
diagnosis  of  the  primary  malady. 


Fig.  127 


Left  pyopneumothoracissubphrenicus.  Note  displacement  of  heart  upward,  the 
upward  compression  of  the  lung,  and  upward  displacement  of  the  diaphragm. 
(Maydl.) 

Abscesses  in  the  right  subphrenic  space  are  mostly  occa- 
sioned by  diseases  of  the  appendix,  liver,  gall-bladder, 
duodenum,  and  right  kidney,  and  by  diffuse  purulent  peri- 
tonitis. The  accumulation  of  pus  in  this  region  depresses 
the  liver,  raises  the  diaphragm,  and  compresses  the  lower 
lobe  of  the  right  lung.     It  gives  rise  to  an  area  of  dulness, 


256     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

with  convexity  upward  at  the  base  of  the  right  chest;  above 
this  area  there  is  normal  pulmonary  resonance  and  normal 
vesicular  breathing.  If  there  is  gas  in  the  abscess  cavity 
its  presence  is  indicated  by  a  characteristic  succussion 
sound  on  shaking  the  patient  and  by  a  zone  of  three-layer 
percussion  sound  at  the  base  of  the  right  chest^ — i.  e.,  from 
above  downward  there  is  first  normal  pulmonary  resonance, 
next  tympanitic  (over  the  gas),  and  lastly  dulness  over  the 
liver.  The  elevated,  dome-shaped  line  of  liver  dulness  in 
front  is  characteristic  of  a  subphrenic  exudate  or  tumor,  and 
between  these  we  can  decide  only  by  exploratory  puncture. 
A'VTien  the  abscess  is  far  back  in  the  subphrenic  space,  the 
dome-shaped,  basal  dulness  is  not  so  marked.  This  dome- 
shaped  area  of  dulness  in  a  patient  who  gives  a  preceding 
history  of  intra-abdominal  suppuration,  or  of  visceral  perfo- 
ration, should  strongly  suggest  the  presence  of  a  subphrenic 
abscess. 

Abscesses  in  the  left  subphrenic  region  are  usually  due 
to  perforations  of  the  stomach,  or  to  diseases  of  the  spleen, 
left  kidney,  and  left  lobe  of  the  liver,  or  to  sacculation  of  pus 
which  results  from  a  diffuse  purulent  peritonitis.  They 
depress  the  left  lobe  of  the  liver,  displace  the  heart  upward, 
and  give  rise  to  the  characteristic  dome-shaped  area  of  basal 
dulness.  If  they  are  gas-containing  abscesses,  there  will 
be  the  characteristic  succussion  on  shaking  the  patient  and  the 
three-layer,  dome-shaped,  basal  percussion  area.  Unless 
the  lung  is  compressed  there  will  be  normal  vesicular  breathing 
down  to  the  dome-shaped  area. 

The  constitutional  evidences  of  subphrenic  suppuration 
are:  pain  and  tenderness  in  the  upper  abdominal  region; 
fever,  either  continuous  or  remittent;  disturbed  nutrition 
and  weakness,  and  increased  leukocytosis. 

K  coexisting  pleural  exudate,  a  by  no  means  infrequent 
complication  to  a  subphrenic  exudate,  and  even  in  some 
instances  the  primary  cause  of  the  subphrenic  abscess,  makes 
the  diagnosis  of  the  subphrenic  condition  much  more  diffi- 
cult. The  previous  history  will  often  aid  us  in  that  it  affords 
a  cause  for  the  subphrenic  suppuration,  and  in  some  in- 
stances exploratory  puncture  will  throw  light  upon  the  diag- 
nosis.    Thus  if  we  introduce  the  needle  deeply  and  trans- 


DISEASES  OF  THE  PERITONEUM  257 

pleiirally  and  aspirate  one  kind  of  pus  from  the  subphrenic 
space,  and  then  on  withdrawing  the  needle  aspirate  a 
different  kind  of  pus  or  serum  from  the  pleural  cavity,  we 
may  assume  that  a  subphrenic  abscess  and  a  pleural  effusion 
are  both  present.  In  the  remaining  doubtful  cases  the  diag- 
nosis will  only  be  made  on  the  operating  table. 

From  a  pleural  exudate  a  subphrenic  abscess  is  readily 
differentiated,  for  with  the  former  there  is,  as  a  rule,  a  his- 
tory of  preceding  pulmonary  or  thoracic  disease,  the  basal 
dulness  is  not  dome-shaped  but  is  concave  upward,  and 
the  breathing  is  altered  up  to  the  top  of  the  chest. 

True  pyopneumothorax  is  distinguished  by  a  history  of 
preceding  pulmonary  disease,  to  which  the  numerous  rales 
over  the  affected  lung  bear  testimony.  The  percussion  note 
over  the  affected  side  of  the  chest  is  tympanitic  above  and 
dull  below,  and  not,  as  in  the  gas-containing  subphrenic 
abscess,  normal  above  with  a  three-layer  zone  of  basal  per- 
cussion sound.  The  normal  vesicular  breathing  at  the  top 
of  the  chest  in  the  latter  condition  is  replaced  in  pyopneu- 
mothorax by  compressed  or  distant  breathing. 


17 


CHAPTER   XXIL 

DISEASES  OF  THE  STOMACH. 

METHODS    OF    EXAMINATION   OF   THE   STOMACH  AND 
ITS  SECRETION. 

Until  comparatively  recent  years  our  diagnosis  of  gas- 
tric affections  was  made  chiefly  from  the  cHnical  symptoms, 
with  such  aid  as  was  to  be  had  from  the  incomplete  methods 
of  physical  examination  then  in  vogue.  Resting  upon  the 
data  obtained  in  this  way,  it  is  not  to  be  wondered  at  that 
the  diagnosis  was  often  entirely  wrong,  and  that  little  benefit 
was  conferred  upon  the  patient  by  prolonged  methods  of 
treatment.  To-day  we  are  considerably  better  off,  inasmuch 
as  the  methods  for  examination  of  the  stomach  and  its 
secretion  are  more  exact  and  accurate;  thus  we  have  learned 
to  ascertain  the  position,  size,  and  motility  of  the  stomach, 
the  composition  of  its  secretion,  and  with  the  fluoroscope 
and  gastrodiaphane  we  can  see  the  outlines  of  the  organ  and 
in  some  instances  the  shadow  of  a  tumor  or  exudate  that 
lies  upon  or  in  its  walls.  Further,  our  understanding  and 
appreciation  of  the  clinical  evidences  of  its  disease  have, 
thanks  to  the  combined  efforts  of  the  internist,  surgeon,  and 
pathologist,  been  considerably  advanced. 

But  though  we  have  made  great  strides  toward  the  more 
accurate  diagnosis  of  stomach  disorders,  considerable  further 
progress  is  necessary,  before  we  will  be  able  to  diagnosticate 
in  their  early  stages  those  diseases  of  the  stomach  which  at 
their  beginning  afford  very  obscure  and  indefinite  symptoms. 
Especially  is  this  true  of  ulcer  and  cancer  of  the  stomach, 
both  of  which  diseases  very  frequently  pass  by  unnoticed 
until  some  serious  life-threatening  complication  arises — e.  g. , 
hemorrhage  or  perforation,  or  until  it  is  too  late  to  effect  a 
radical  cure.     Such  early  diagnosis   is  not,  however,  always 


DISEASES  OF  THE  STOMACH  259 

possible  from  the  data  which  are  to  be  obtained  from  the 
cHnical  history,  the  physical  examination,  and  the  chemical 
analysis  of  the  gastric  secretion;  and  in  the  doubtful  cases 
we  must  have  the  aid  which  is  afforded  by  diagnostic  lapa- 
rotomy. The  risks  attending  this  procedure  are  slight  and 
are  not  to  be  compared  with  the  immense  benefit  that  may 
accrue  to  the  patient  from  an  early  accurate  diagnosis  of 
his  malady.  A  good  working  rule  for  its  employment  is 
the  following:  "If  the  symptoms  are  progressive,  and  no 
adequate  constitutional  or  local  cause  for  them  can  be  found, 
and  no  benefit  is  derived  from  a  carefully  instituted  internal 
and  local  treatment,  diagnostic  laparotomy  is  to  be  considered 
not  only  admissible  but  obligatory." 

Turning  now  to  the  examination  of  the  stomach,  it  is 
important  to  ascertain  its  position,  its  size,  its  muscular 
function,  the  presence  of  abnormal  tumor  formation,  the 
chemical  composition  of  its  secretion,  and  the  shadow  pictures 
which  are  afforded  by  the  fluoroscope  and  gastrodiaphane. 

Position. — The  position  of  the  organ  is  determined  by 
percussion  and  palpation  in  its  empty  and  distended  state, 
and  also  by  fluoroscopic  and  gastrodiaphanic  examination. 
The  viscus  is  best  distended  with  a  Davidson  syringe 
through  a  stomach  tube  passed  just  beyond  the  cardiac 
orifice.  Seidlitz  powders  are  less  satisfactory  for  this  pur- 
pose. A  recent  hemorrhage,  or  the  suspicion  of  an  ulcer, 
or  perforation,  contraindicates  distention,  which  in  any 
instance  should  not  be  carried  to  excessive  degrees.  A 
large  dose  of  bismuth  subnitrate  should  be  given  before 
fluoroscopic  examination. 

The  normal  position  of  the  stomach  is  a  vertical  one; 
its  cardiac  end  lies  behind  the  costal  cartilages  of  the  sixth 
and  seventh  rib;  its  pyloric  end  just  to  the  right  of  the 
sternum  at  the  level  of  the  tip  of  the  ensiform  cartilage. 
Its  highest  and  lowest  points  vary  according  to  its  state  of 
distention.  In  the  fully  distended  state,  the  highest  point 
corresponds  to  the  top  of  the  fundus  and  lies  in  the  mam- 
mary line  behind  the  fifth  rib;  and  the  lowest  point  several 
inches  above  the  umbilicus.  (See  Fig.  112,  p.  220.)  In  an 
empty  condition  the  stomach  is  like  a  hollow  tube,  the  greater 
curvature  being  almost  parallel  with  the  lesser. 


260     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

Changes  in  position  are  due  to  gastroptosis,  or  neoplasms, 
or  adhesions. 

Size. — The  size  of  the  stomach  is  variable;  normally  we 
expect  the  lower  border  in  the  fully  distended  state  of  the 
viscus  to  lie  several  fingers'  breadth  above  the  umbilicus, 
and  its  upper  border  to  reach  to  the  fifth  rib  in  the  mam- 
mary line.  If  the  former  descends  below  the  umbilicus, 
with  constancy  of  the  upward  extension,  dilatation  may  be 

Fig. 128 


Stomach  inflated,  showing  gastroptosis.    (Von  Bergmann.) 


assumed.  Such  dilatation  is  due  to  pyloric  stenosis  and  to 
relaxation  or  acute  paralysis  of  the  muscular  coat  of  the 
organ. 

The  anatomical  relation  of  growths  and  exudates  around 
the  stomach  can  be  best  determined  when  the  stomach  and 
colon  are  distended.  Only  the  pyloric  and  lower  portions 
of  the  body  of  the  stomach  are  accessible  to  palpation,  and 
that  in  the  space  between  the  left  hepatic  lobe  and  the 
costal  margin.     When  the  stomach  is  distended  the  upper 


DISEASES  OF   THE  STOMACH  261 

border  may,  upon  deep  expiration,  be  felt  to  slip  upward 
under  the  ribs  and  costal  cartilages. 

Motor  Function. — The  motor  function  of  the  stomach  is 
determined  by  giving  the  patient  a  test  meal  in  the  evening 
and  siphoning  out  the  organ  on  the  following  morning.  If 
food  particles  are  obtained  it  points  to  muscular  insuffi- 
ciency. This  is  present  in  acute  dilatation  of  the  organ 
and  in  the  dilatation  that  accompanies  long-standing  pyloric 
stenosis.  If  large  amounts  of  clear  gastric  juice  (above 
100  c.c.)  are  obtained,  it  points  to  hypersecretion,  a  con- 
dition that  accompanies  gastric  ulcer  or  that  results  from 
a  nervous  disturbance. 

Chemical  Composition  of  Gastric  Juice. — The  chemical 
composition  of  the  gastric  juice  is  determined  by  an  exami- 
nation of  the  gastric  contents,  which  are  obtained  by  siphon- 
ing out  the  stomach  one  hour  after  a  test  meal  has  been 
taken.  The  test  meal  should  consist  of  a  cup  of  black,  un- 
sweetened coffee  or  tea  and  one  piece  of  toast,  or,  better, 
one  shredded-wheat  biscuit. 

The  examination  is  made  for: 

1.  Acidity,  with  blue  litmus  paper. 

2.  Free  hydrochloric  acid.  A  few  drops  of  a  weak  watery 
solution  of  methyl  violet  are  added  to  1  c.c.  of  the  gastric 
juice,  and  to  a  similar  quantity  of  distilled  water.  In  the 
presence  of  free  hydrochloric  acid  a  deep-blue  color  appears. 

Or  a  few  drops  of  Ginzberg's  solution  (composed  of  two 
parts  of  phloroglucin,  one  part  of  vanillin,  in  three  parts  of 
absolute  alcohol)  are  dried  on  a  porcelain  dish  over  the 
Bunsen  flame.  A  few  drops  of  filtered  gastric  juice  are 
added  and  the  dish  warmed.  In  the  presence  of  free  hydro- 
chloric acid,  a  brilliant  red  color  results.  In  chronic  atrophic 
gastritis  and  carcinoma  there  may  be  an  absence  of  free 
hydrochloric  acid. 

3.  Lactic  acid.  A  few  drops  of  gastric  juice  are  added 
to  a  test-tube  full  of  Uffelman's  reagent,  which  is  made  as 
follows:  To  10  c.c.  of  a  1  per  cent,  solution  of  carbolic  acid 
are  added  1  to  2  drops  of  liquor  ferri  sesquichlorati.  In 
the  presence  of  large  amounts  of  lactic  acid  a  canary  yellow 
color  appears. 

The  presence  of  large  amounts  of  lactic  acid  points  to 


262     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

gastric  stagnation,  absence  of  hydrochloric  acid,  and  dimi- 
nution of  ferments.  These  conditions  are  usually  found  in 
pyloric  carcinoma  with  dilatation  of  the  stomach. 

4.  Peptones.  To  a  cold,  strongly  alkalinized  solution  of 
gastric  juice  is  slowly  added  a  1  per  cent,  solution  of  copper 
sulphate.  A  deep-red  color  points  to  presence  of  peptones 
(Biuret  reaction).  Its  absence  indicates  absent  free  hydro- 
chloric acid  and  ferments,  conditions  found  in  chronic 
atrophic  gastritis  and  carcinoma. 

5.  The  total  acidity.  Ten  c.c.  of  filtered  gastric  con- 
tents are  diluted  with  two  or  three  times  the  quantity  of 
water,  and  a  few  drops  of  alcoholic  phenolphthalein  added. 
Alkalies  turn  the  latter  red;  in  acid  or  neutral  solutions  it 
remains  colorless.  A  decinormal  sodium  hydrate  solution 
is  added  from  a  graduated  burette  to  the  diluted  gastric 
juice  with  phenolphthalein  until  a  weak  red  color  permanently 
appears.  From  the  number  of  cubic  centimetres  of  sodium 
hydrate  used,  the  amount  of  total  acids  is  computed. 
Thus,  if  for  the  neutralization  3  to  4  c.c.  of  decinormal 
sodium  hydrate  solution  were  used,  for  100  c.c.  of  gastric 
juice,  30  to  40  c.c.  would  be  used,  which  is  put  down  as  the 
total  acidity.    This  is  about  the  normal. 


ULCER  OF  THE  STOMACH. 

A  diagnosis  of  ulceration  of  the  stomach  can,  as  a  rule, 
be  made  from  the  symptoms  to  which  such  a  condition 
gives  rise — viz.,  sharp  cutting  pain  in  the  epigastrium  which 
shoots  into  the  back  and  is  possibly  made  worse  by  eating, 
eructations  and  vomiting  of  intensely  acid  material  soon  after 
taking  food,  heartburn,  anaemia,  impoverished  nutrition, 
hyperacidity  of  the  gastric  juice,  local  tenderness  in  the  stom- 
ach region,  a  Head  zone,  and  when  the  edges  of  the  ulcer 
are  very  much  thickened,  a  tumor  in  the  stomach  region. 
The  hyperacidity  of  the  gastric  juice,  the  Head  zone,  and 
the  tumor  are  very  inconstant  manifestations  and  are  con- 
sequently of  little  aid  in  making  the  diagnosis.  In  the 
majority  of  cases  the  subjective  symptoms  alone  are  present, 
and  as  these  very  closely  resemble  those  which  are  occasioned 


DISEASES  OF   THE  STOMACH  263 

by  calculi  in  the  gall-bladder,  duodenal  ulcer,  and  epigastric 
hernia,  we  often  find  it  very  difiicult  to  make  the  differential 
diagnosis  between  these  last-named  conditions  and  gastric 
ulcer. 

With  gallstone  disease,  however,  there  is  apt  to  be  a  his- 
tory of  repeated  attacks  of  biliary  colic,  some  of  which  have 
been  followed  by  jaundice,  and  after  some  of  the  attacks 
of  colic  stones  may  have  been  found  in  the  stools.  Further- 
more, the  pain  in  gastric  ulcer  is  likely  to  be  worse  right 
after  eating,  whereas  in  gallstone  disease  the  pain  commences 
two  or  three  hours  after  a  meal.  A  history  of  preceding 
attacks  of  inflammation  of  the  gall-bladder  or  the  occur- 
rence at  any  time  of  a  cholecystitis  with  fever  and  distention 
of  the  viscus  are  important  data  for  making  the  differentia- 
tion. We  must  not  forget  that  gallstone  disease  and  gastric 
ulcer  may  coexist,  and  that  the  contraction  of  perigastric 
adhesions  which  have  originated  from  a  calculous  chole- 
cystitis may  occasion  a  benign  pyloric  stenosis  that  in  every 
detail  clinically  resembles  the  stenosis  which  follows  the 
cicatrization  of  a  pyloric  ulcer.  In  such  cases  a  history  of 
preceding  attacks  of  cholecystitis  gives  us  a  clue  to  the 
diagnosis. 

Duodenal  ulcer  is  distinguished  from  pyloric  ulcer  by  the 
fact  that  the  pain  is  located  more  to  the  right  and  comes  on 
two  or  three  hours  after  a  meal.  The  occasional  occurrence 
of  jaundice  and  the  radiation  of  the  pain  to  the  right  shoulder 
which  occur  in  some  of  the  cases  of  duodenal  ulcer  may  lead 
to  an  erroneous  diagnosis  of  biliary  lithiasis;  the  differentiation 
is,  however,  readily  to  be  made  from  the  absence  of  attacks 
of  biliary  colic  and  cholecystitis. 

An  epigastric  hernia  is  readily  detected  by  physical  ex- 
amination, and  if  in  every  case  presenting  gastric  symptoms 
we  remember  to  examine  for  it,  many  mistakes  in  diagnosis 
will  be  avoided. 

It  seems  almost  impossible  that  any  difficulty  should  be 
experienced  in  differentiating  two  such  radically  different 
conditions  as  gastric  ulcer  and  gastric  cancer;  and  yet  an 
ulcer  with  thickened  edges  that  gives  rise  to  a  palpable  tumor 
in  the  epigastrium  may  readily  be  mistaken  for  a  carcinoma 
of  the  stomach.     If  we  remember  the  similarity  of  the  gas- 


264     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

trie  symptoms  in  both  conditions,  the  inconstancy  of  the 
changes  in  the  chemical  composition  of  the  gastric  juice 
that  attend  them,  and  the  unreliabiHty  of  the  changes  in 
the  blood  that  are  associated  with  carcinoma  and  ulcer, 
we  will  appreciate  the  difficulty  that  arises  in  their  differ- 
entiation. This  difficulty  becomes  all  the  greater  if  we  also 
remember  that  carcinoma  only  too  often  develops  on  the 
base  of  an  old  ulcer.  The  only  safe  plan  of  procedure  in 
such  cases  is  to  explore  by  laparotomy  every  palpable  tumor 
of  the  stomach,  and  that  without  too  much  delay.  Explo- 
ratory laparotomy  in  these  cases  is  not  only  admissible,  but 
obligatory. 

As  was  stated  above,  carcinoma  frequently  develops  on 
the  base  of  an  old  ulcer,  and  there  are  no  signs  by  which  the 
change  from  a  benign  to  a  malign  affection  can  be  detected. 

Our  experience  with  such  cases  has  taught  us  that  when 
a  patient  who  has  or  had  a  gastric  ulcer  suffers  with  an 
aggravation  or  recurrence  of  the  symptoms  with  coincident 
loss  of  weight  and  strength,  and  does  not  improve  under 
appropriate  medical  treatment,  exploratory  laparotomy  is 
the  safest  procedure. 

The  later  stages  of  cancer,  especially  when  located  at 
the  pylorus,  are  readily  differentiated  from  ulcer.  The 
marked  wasting  and  loss  of  strength,  the  cachexia,  the 
anacidity  of  the  gastric  juice,  the  absence  of  ferments,  and 
the  presence  of  lactic  acid  therein  when  the  growth  is 
at  the  pylorus,  all  bear  strong  testimony  to  the  existence 
of  a  carcinoma;  testimony  that  is  considerably  strengthened 
if  a  hard,  nodular  tumor  and  supraclavicular  glandular 
enlargement  are  to  be  felt. 

In  connection  with  gastric  ulcer  we  must  not  forget  the 
complications  to  which  it  may  give  rise — viz.,  hsematemesis 
and  melsena,  pyloric  stenosis  with  secondary  gastric  dilata- 
tion, acute  perforation,  chronic  perforation  with  perigas- 
tritis, and  subphrenic  abscess.  The  diagnosis  of  benign 
pyloric  stenosis,  acute  perforation,  and  subphrenic  abscess 
will  be  considered  on  pages  270  and  274. 

Chronic  or  gradual  perforation  often  gives  rise  to  peri- 
gastritis, with  the  formation  of  an  exudate  around  the  per- 
foration.   The  exudate  may  become  adherent  to  the  anterior 


DISEASES  OF  THE  STOMACH  265 

abdominal  wall  or  to  neighboring  organs,  and  when  it  is 
originally  situated  in  the  bursa  omentalis  it  may  burrow 
upward  into  the  subphrenic  regions.  Such  an  exudate  is 
hard,  very  sensitive,  has  indefinite  borders  and  a  smooth 
surface.  Should  it  break  down  into  pus  the  temperature 
would  rise  and  the  leukocytes  increase  in  numbers.  The 
tumor  formed  by  a  perigastric  exudate  may  simulate  cancer 
of  the  stomach,  from  which  the  clinical  history  and  the 
hyperacidity  of  the  gastric  juice  differentiate  it.  From  a 
neoplasm  of  the  colon  a  perigastric  exudate  is  distinguished 
by  its  clinical  course  and  the  symptoms  which  attend  it  and 
by  colonic  distention. 

Perigastric  adhesions  from  ulcer,  gall-bladder,  or  pan- 
creatic disease  may  cause  a  benign  pyloric  stenosis.  A 
clinical  history  pointing  to  ulcer  and  the  examination  of 
the  stomach  contents  will  help  to  establish  the  cause  of 
the  perigastritis. 


NEOPLASMS  OF  THE  STOMACH. 

Benign  as  well  as  malign  neoplasms  develop  in  the  walls 
of  the  stomach.  The  former  grow  slowly,  attain  consider- 
able size,  have  a  smooth,  hard  surface,  and  cause  no  dis- 
turbances in  gastric  function  or  general  nutrition.  The 
latter,^  on  the  other  hand,  grow  rapidly,  give  rise  to  chemi- 
cal changes  in  the  gastric  juice  and  disturb  gastric  motility, 
and  very  early  in  their  course  occasion  marked  emaciation 
and  cachexia. 

It  is  unfortunate  for  our  patients  that  too  many  physicians 
still  rely  upon  the  presence  of  a  palpable  tumor  for  the  diag- 
nosis of  gastric  cancer,  because  when  a  tumor  becomes  pal- 
pable it  is  too  late  to  effect  a  cure  of  the  malady.  If  we  are 
to  hold  out  to  patients  afflicted  with  this  disease  any  hope  for 
a  radical  cure,  we  must  make  the  diagnosis  before  a  tumor 
becomes  palpable.  Czerny  has  stated  "that  no  cancer  of  the 
stomach  should  be  operated  upon  radically  at  a  time  when  its 

1  The  carcinomata  are  more  frequent  than  the  sarcomata.  The  latter,  according 
to  Fen  wick,  constitute  from  5  to  7  per  cent,  of  stomach  tumors.  They  are  often  asso- 
ciated with  sarcomata  of  the  ovaries. 


266     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

recognition  as  a  tumor  has  become  certain,"  and  Kraske  is  of 
the  opinion  "that  operation  for  pyloric  cancer  is  desirable 
only  when  a  tumor  cannot  be  felt,  and  when  on  this  account 
no  positive  diagnosis  is  possible."  A  palpable  tumor  is 
usually  one  of  the  late  manifestations  of  the  malady,  and 
while  its  presence  in  conjunction  with  other  clinical  symp- 
toms affords  almost  conclusive  evidence  of  the  existence  of 
a  cancer,  it  comes  too  late  to  permit  us  to  wait  for  it  before 
establishing  a  diagnosis.  In  the  early  stages  of  the  malady 
we  must  rely  upon  other  clinical  evidences  than  the  presence 
of  a  tumor  for  making  the  diagnosis;  these  evidences,  as 
Kraske  states,  are  not  positive,  but  they  are  strongly  sus- 
picious and  warrant,  nay,  even  oblige,  us  to  resort  to  ex- 
ploratory laparotomy  in  order  to  ascertain  their  cause. 

The  most  important  of  the  early  signs  of  cancer  of  the 
stomach  are  (1)  the  occurrence  of  dyspeptic  symptoms  in  a 
patient  who  is  beyond  the  fortieth  year  of  life;  (2)  changes 
in  the  chemical  composition  of  the  gastric  juice;  (3)  dis- 
turbances in  swallowing  or  in  gastric  motility;  (4)  a  sec- 
ondary anaemia. 

The  earliest  manifestations  of  the  disease  are  usually 
of  a  dyspeptic  character.  These  may  remain  the  only  evi- 
dences during  the  early  stages — e.  g.,  when  the  neoplasm  is 
limited  to  the  body  of  the  organ — or  to  them  may  be  added 
the  evidences  of  pyloric  or  cardiac  stenosis  when  the  new- 
growth  is  located  at  one  or  the  other  of  the  orifices  of  the 
organ. 

It  would  be  better  for  our  patients  if  we  were  to  suspect 
every  one  beyond  forty  who  suddenly  presents  gastric  symp- 
toms as  being  affected  with  carcinoma  and  devoted  our 
efforts  to  disprove  its  presence,  than  if  we  look  upon  these 
manifestations  with  a  favorable  eye  until  the  development  of 
a  tumor  dispels  our  false  hopes  of  their  benign  character. 

The  gastric  juice  in  the  early  stages  of  carcinoma  of  the 
stomach  usually  contains  no  free  hydrochloric  acid;  in  those 
instances  in  which  the  cancer  develops  on  the  base  of  an 
ulcer  there  may  be  a  hyperacidity.  The  absence  of  digestive 
ferments  (pepsin  and  rennet)  is  also  an  inconstant  phenom- 
enon. Several  other  conditions  besides  cancer — e.  g.,  chronic 
catarrh  of  the  stomach  and  atrophy  of  the  gastric  mucosa — 


DISEASES  OF   THE  STOMACH  267 

are  sometimes  accompanied  by  a  marked  diminution  or 
absence  of  free  hydrochloric  acid  from  the  gastric  juice. 
A  chronic  catarrh,  however,  runs  a  lengthy  course  with 
improvements  and  regressions,  and  with  no  grave  impairment 
of  the  general  condition.  Atrophy  of  the  gastric  mucosa, 
while  it  may  determine  an  alarming  state  of  cachexia,  has 
likewise  a  protracted  course  and  will  not  be  ordinarily 
complicated  by  disorders  of  motility.  The  absence  of  motor 
insufficiency  will  likewise  differentiate  the  cases  of  gastric 
atrophy  due  to  cancer  in  other  parts  of  the  body  from  pyloric 
cancer.  The  greatest  difficulties  will  be  experienced  in  the 
differentiation  between  cancer  and  the  atrophy  which  is  due 
to  gastric  distention  from  benign  stenosis  of  the  pylorus. 
Here  again  the  longer  duration  of  the  malady  is  important 
for  differentiation. 

Should  the  cancer  be  located  at  the  pyloric  orifice,  there 
will  he  quite  early  manifested  an  insufficient  motor  function, 
with  vomiting,  stagnation  of  contents  within  the  viscus,  and 
the  presence  of  lactic  acid  in  the  gastric  juice.  These 
additional  symptoms  make  the  early  diagnosis  much  easier. 
All  these  symptoms  may  again  attend  a  benign  pyloric 
stenosis  with  atrophy  of  the  mucous  membrane,  but  the 
progress  of  the  symptoms  in  this  latter  condition  is  very 
slow,  and  is  usually  preceded  by  the  symptoms  of  gastric 
ulcer. 

Should  the  cancer  be  located  at  the  cardiac  "orifice,  an 
increasing  difficulty  in  swallowing  with  absence  of  or  delay 
in  the  second  swallowing  sound  will  materially  aid  in  estab- 
lishing an  early  diagnosis. 

During  these  early  stages  the  blood  frequently  shows  a 
secondary  anosmia,  the  haemoglobin  falling  to  30  or  40  per 
cent. 

While  the  symptoms  just  detailed  are  not  positive  proof 
of  gastric  cancer,  they  are  nevertheless  strong  enough  evi- 
dence to  justify  us  in  advising  an  exploratory  laparotomy 
in  order  to  ascertain  their  cause.  The  question  may  be 
summed  up  as  follows:  When  a  patient  beyond  forty  pre- 
sents the  symptoms  of  an  intractable  chronic  dyspepsia, 
with  absence  of  free  hydrochloric  acid  in  the  gastric  juice 
and  with  evidences  of  motor  insufficiency  of  the  stomach 


268     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

(such  as  vomiting,  stagnation  in  the  stomach,  and  lactic 
acid  in  the  gastric  juice),  and  continuously  loses  weight, 
he  should  be  urgently  advised  to  have  an  exploratory  lapa- 
rotomy done  in  order  to  ascertain  the  cause  of  the  symp- 
toms. 

Difficult  as  is  the  early  diagnosis  of  gastric  cancer,  so 
easy  does  it  become  after  the  development  of  a  tumor, 
which,  in  conjunction  with  the  symptoms  above  detailed, 
is  almost  conclusive  evidence  of  this  disease. 

The  tumor  is  hard  and  nodular;  when  not  adherent  it 
enjoys  respiratory,  active,  and  passive  motility,  and  should 
there  be  gastroptosis  it  may  have  a  very  low  site,  even  sag- 
ging into  the  right  kidney  region.  If  it  is  located  upon  the 
posterior  wall  or  lesser  curvature,  it  is  obscured  by  disten- 
tion of  the  organ.  Colonic  distention  causes  the  tumor  to 
ascend. 

The  tumor  of  a  gastric  cancer  is  to  be  distinguished  from 
tumors  of  the  colon,  omentum,  gall-bladder,  liver,  pancreas, 
and  abdominal  wall,  and  from  a  floating  kidney  or  spleen. 

Colonic  Tumors. — Colonic  tumors  are  differentiated  by 
gastric  and  colonic  distention,  the  absence  of  chemical 
changes  in  the  gastric  juice,  and  the  presence  of  stenotic 
symptoms  of  the  colon  with  colonic  erections.  (See  Chronic 
Intestinal  Obstruction,  p.  283.) 

Omental  Tumors. — Omental  tumors  are  elongated  in 
form  and  are  pushed  downward  by  gastric  and  colonic 
distention.  If  they  are  adherent  in  front  of  the  stomach, 
distention  of  the  latter  makes  them  more  prominent.  They 
are  not  attended  with  chemical  changes  in  the  gastric 
juice. 

Tumors  of  Gall-bladder. — With  tumors  of  the  gall- 
bladder there  is  a  history  of  previous  attacks  of  biliary  colic 
and  cholecystitis,  possibly  of  jaundice,  and  of  calculi  being 
found  in  the  stools.  The  gastric  secretion  is  normal.  The 
tumor  has  the  shape  of  a  gall-bladder. 

Tumors  of  Liver — Tumors  of  the  left  lobe  of  the  liver 
are  not  affected  by  gastric  distention. 

Tumors  of  Pancreas. — Tumors  of  the  pancreas  are 
obscured  by  gastric  and  colonic  distention;  the  gastric 
secretion  is  normal;  there  may  be  jaundice;  cachexia  occurs 


DISEASES  OF   THE  STOMACH  269 

early  and  is  marked.    There  are  evidences  of   pyloric  ste- 
nosis. 

Wandering  Spleen. — The  wandering  spleen  is  easily 
recognized  by  its  notched  border;  the  kidney  by  its  shape. 
Both  organs  can  be  replaced  into  their  respective  posi- 
tions. 


CHAPTER  XXIIL 

DISEASES  OF  THE  STOMACH  {Continued). 
PYLORIC  STENOSIS. 

Moderate  or  severe  forms  of  congenital  pyloric  stenosis, 
which  are  presumably  due  to  a  spasm  of  the  normal  or  hyper- 
trophied  pyloric  muscle,  are  readily  recognized  from  the  symp- 
toms which  they  occasion.  Either  right  after  birth  or  in  the 
course  of  the  first  year  of  its  life,  the  infant  persistently 
vomits  all  ingesta,  and  that  without  any  cause.  In  spite 
of  change  in  and  regulation  of  the  diet  and  of  all  local  treat- 
ment, the  vomiting  continues  and  soon  causes  the  death  of 
the  patient  from  inanition.  The  stomach  is  rarely  much 
dilated;  occasionally  the  hypertrophied  pylorus  is  to  be 
felt  as  a  distinct  tumor. 

The  acquired  forms  of  pyloric  stenosis  are  either  benign 
or  malign  in  character;  the  former  are  due  to  the  contrac- 
tion of  a  healed  pyloric  ulcer,  to  kinking  of  the  pylorus  by 
perigastric  adhesions  or  to  pressure  on  the  pylorus — e.  g., 
by  an  exudate  or  an  enlarged  gall-bladder  or  a  floating 
kidney;  the  latter  are  due  to  malignant  disease  of  the  pylorus 
or  adjacent  viscera. 

The  existence  of  a  'pyloric  stenosis  is  not  hard  to  diagnos- 
ticate, for  the  disturbed  gastric  motility  which  it  occasions  bears 
strong  testimony  thereof.  The  evidences  of  such  disturbed 
motility  are  lomiting  (often  of  large  quantities  of  food,  some 
of  which  may  have  been  ingested  several  days  before),  more 
or  less  prolongation  of  the  time  in  which  the  stomach  should 
empty  itself  after  a  meal,  and  in  the  more  advanced  cases 
stagnation  of  food  within  the  stomach,  gastric  eructations  and 
more  or  less  gastric  dilatation,  the  lower  border  of  the  viscus 
in  its  distended  state  descending  below  the  umbilicus. 

The  character  of  the  stenosis  is  not  always  so  easy  to 


DISEASES  OF   THE  STOMACH  271 

determine.  In  most  cases  a  preceding  history  of  gastric 
ulcer,  of  cholelithiasis  with  cholecystitis,  of  chronic  pan- 
creatitis, or  the  physical  evidences  of  a  floating  kidney 
will  suggest  the  possibility  of  its  benign  character,  a  possi- 
bility that  is  rendered  more  certain  if  the  gastric  juice  con- 
tains free  hydrochloric  acid  and  ferments  and  no  lactic 
acid,  and  if  the  haemoglobin  percentage  remains  fairly  high. 
In  some  cases,  however,  the  distention  of  the  stomach 
which  follows  a  benign  stenosis  occasions  an  extreme  grade 
of  atrophy  of  the  gastric  mucosa,  in  consequence  of  which 
the  gastric  secretion  will  contain  no  free  hydrochloric  acid 
and  no  ferments,  but  will  contain  lactic  acid;^  the  emacia- 
tion and  cachexia  may,  furthermore,  be  just  as  marked  as 
is  present  in  malignant  disease  of  the  organ.  In  these  cases 
the  differential  diagnosis  is  attended  with  a  great  deal  of 
difficulty,  and  even  the  presence  of  a  tumor  at  the  pylorus 
may  not  be  sufficient  to  distinguish  the  two  conditions, 
for  the  tumor  may  represent  an  ulcer  with  thickened  edges 
or  a  perigastric  exudate  or  a  contracted  adherent  gall- 
bladder, as  well  as  a  malignant  neoplasm.  The  previous 
history  may  help  us  in  the  differentiation,  but  as  surgical 
interference  is  indicated  to  relieve  the  stenosis  whatever 
its  cause,  no  time  should  be  lost  in  proceeding  to  exploratory 
laparotomy. 


ACUTE  DILATATION  OF  THE  STOMACH. 

This  follows  a  variety  of  local  and  constitutional  diseases 
and  also  overfeeding.  The  condition  manifests  itself  with 
a  sudden  onset  of  persistent  and  uncontrollable  vomiting 
of  large  amounts  of  acid  material,  with  marked  prostration 
and  collapse  (weak  pulse,  subnormal  temperature,  and 
diminished  urine  elimination).  The  stomach  is  much  dilated, 
the  greater  curvature  descending  considerably  below  the 
umbilicus. 


1  The  presence  of  lactic  acid  in  the  gastric  juice  depends  upon  the  absence  therefrom 
of  hydrochloric  acid  and  of  ferments  and  upon  the  presence  of  motor  insufficiency; 
it  is  consequently  found  in  the  benign  as  well  as  the  malign  forms  of  pyloric  stenosis 
attended  with  atrophy  of  gastric  mucosa. 


272     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 


HOUR-GLASS  STOMACH. 

The  evidences  of  disturbed  gastric  motility — viz.,  repeated 
vomiting,  stagnation  of  food  within  the  stomach,  dilatation 
of  the  organ,  and  disturbed  nutrition  and  emaciation — 
may  also  be  due  to  an  hour-glass  condition  of  the  viscus. 
This  is  always  acquired  and  is  occasioned  by  a  constriction 
of  the  stomach  anywhere  between  its  two  orifices.  The 
constriction  may  be  due  to  perigastric  adhesions,^  or  to 
contraction  and  spasm  of  the  stomach  wall  at  the  site  of  a 
chronic  ulcer,  or  to  an  annular  neoplasm  of  the  stomach. 

The  condition  is  to  be  recognized  by  physical  examina- 
tion, and  its  underlying  cause  determined  from  the  anamnesis 
and  from  the  examination  of  the  gastric  secretion.  Thus 
a  preliminary  gallstone  history,  or  a  history  of  gastric  ulcer 
with  hyperacid  gastric  juice  would  indicate  a  benign  type  of 
hour-glass  contraction,  whereas  anacidity  of  the  gastric  juice, 
with  the  presence  of  lactic  acid  therein,  a  low  haemoglobin 
percentage,  and  a  hard,  nodular,  palpable  tumor  of  the 
stomach,  would  point  to  malignant  disease  as  the  cause 
therefor. 

According  to  Moynihan  the  following  signs  point  clearly 
to  hour-glass  stomach: 

1.  If  a  stomach  tube  be  passed  and  the  viscus  washed 
out  with  a  known  quantity  of  fluid,  the  loss  of  a  certain 
quantity  will  be  observed  when  the  return  fluid  is  measured 
(Woelfler's  first  sign). 

2.  If  the  stomach  is  washed  out  until  it  is  clean,  a  sudden 
rush  of  foul,  ill-smelling  fluid  may  occur;  or  if  the  stomach 
is  washed  clean  and  a  tube  is  reinserted  after  a  few  minutes, 
several  ounces  of  offensive  fluid  may  escape  (Woelfler's 
secondary  sign). 

3.  Paradoxical  dilatation  of  the  stomach  (Jaworski).  The 
stomach  is  first  dilated  and  a  succussion  splash  obtained; 
the  stomach  tube  is  passed  and  the  viscus  apparently  emptied; 

1  Perigastric  adhesions  have  as  their  most  frequent  cause  an  ulceration  of  the 
stomach  or  duodenum  and  a  calculous  cholecystitis. 


DISEASES  OF   THE  STOMACH  273 

on  again  palpating,  the  splashing  succussion  sound  will  be 
again  elicited.  Jaboulay  has  added  to  this  the  following: 
If  the  cardiac  pouch  be  filled  with  water,  the  splashing 
succussion  sound  may  still  be  obtained  in  the  pyloric  por- 
tion. 

4.  Von  Eiselsberg  observed  that  on  distention  of  the 
stomach  with  a  Seidlitz  powder,  a  bulging  of  the  left  side 
of  the  epigastrium  was  produced.  After  a  few  moments 
this  subsided  and  concomitantly  there  was  a  bulging  of  the 
right  side. 

5.  Von  Eiselsberg  also  heard  a  rumbling  sound  at  the 
site  of  the  constriction  as  the  gas  passed  through  the  nar- 
rowed orifice. 

6.  Moynihan  has  found  the  following  of  service:  The 
stomach  resonance  is  percussed;  the  viscus  is  then  distended 
with  a  Seidlitz  powder.  After  a  few  minutes  there  is  an 
enormous  increase  in  the  resonance  of  the  upper  part  of 
the  stomach,  while  the  lower  part  remains  unaltered.  If 
the  pyloric  pouch  can  be  felt  or  seen,  the  diagnosis  is  clear, 
for  the  upper,  distended  pouch  is  the  cardiac  segment. 

7.  Schmidt-Monard  and  Eichhorst  have  noticed  a  dis- 
tinct sulcus  between  the  two  distended  pouches,  and  one 
pouch  can  be  emptied  into  the  other. 

8.  Ewald  distends  the  stomach  and  examines  with  the 
gastrodiaphane;  the  transillumination  is  seen  only  in  the 
cardiac  pouch;  the  pyloric  segment  remains  dark. 


18 


CHAPTER   XXIV. 

PERFORATIONS  INTO  THE  PERITONEAL  CAVITY. 

Perforation  of  a  hollow  viscus,  infected  cyst,  or  abscess 
into  the  peritoneal  cavity  is  usually  attended  with  local  or 
diffuse  extravasation  of  infected  material  therein,  and  it  is 
this  latter  circumstance  that  gives  to  this  accident  its  sinister 
significance.  Two  problems  stare  us  in  the  face  in  every 
case  of  suspected  perforation:  the  first  is  to  decide  whether 
a  perforation  has  really  taken  place,  and  if  it  has,  the  next 
thing  to  determine  is  whether  the  attending  extravasation 
of  intestinal  contents  or  other  infected  material  is  confined 
by  limiting  adhesions  to  one  part  of  the  peritoneal  cavity  or 
whether  it  is  free  in  the  general  peritoneal  cavity. 

The  study  that  has  been  recently  expended  upon  this  sub- 
ject has  enabled  us  to  diagnosticate  with  a  fair  amount  of 
certainty  the  acute  and  sudden  and  the  slow  and  gradual 
perforations  that  are  attended  with  local  or  diffuse  extravasa- 
tion of  septic  material ;  but  the  slow  and  gradual  perforations 
which  are  not  attended  with  extravasation  because  of  a 
previous  adhesion  of  the  diseased  focus  to  a  neighboring 
viscus  or  part  of  the  abdominal  wall  are  very  difficult  of 
recognition,  and  are  sometimes  only  detected  on  the  post- 
mortem table. 

But  though  we  are  in  a  position  to  detect  a  perforation 
that  is  attended  with  extravasation  of  septic  material,  we 
are  absolutely  unable,  from  our  present  knowledge  and 
experience,  to  positively  state  at  an  early  stage  after  such  a 
perforation  has  occurred  whether  or  not  the  resulting  extrav- 
asation will  be  confined  by  adhesions  to  one  portion  of  the 
peritoneal  cavity;  and  yet  this  is  a  most  important  question. 
For  if  the  extravasation  of  infected  material  is  into  the  free 
peritoneal  cavity,  an  immediate  laparotomy  with  repair  of 
the  perforation  must  be  undertaken  if  we  are  to  prevent  the 


PERFORATIONS  INTO   THE  PERITONEAL   CAVITY      275 

diffusion  of  the  septic  matter  throughout  the  peritoneal 
cavity  with  the  consequent  development  of  a  diffuse  septic 
peritonitis;  and  yet  such  immediate  laparotomy  may  be  most 
undesirable  on  account  of  the  patient's  otherwise  poor  general 
condition.  If,  however,  we  could  foretell  that  the  extravasa- 
tion would  be  confined  to  a  local  area  of  the  peritoneum,  this 
immediate  interference  could  be  delayed,  and  if  an  abscess 
formed  at  the  site  of  the  extravasation  it  could  be  evacuated 
when  it  had  become  well  walled  off  from  the  free  peritoneal 
cavity.  At  such  a  time  the  operation  would  be  comparatively 
simple,  amounting  only  to  incision  and  drainage  of  an  extra- 
peritoneal abscess,  and  the  patient  would  be  in  many  instances 
far  better  able  to  withstand  it. 

We  have,  however,  not  yet  learned  to  recognize  in  which 
cases  the  extravasation  will  remain  localized,  and  until  we 
can  do  so  we  shall  have  to  operate  all  cases  immediately  upon 
making  the  diagnosis  of  a  perforation,  in  order  to  prevent  in 
some  of  them  the  possible  complication  of  diffuse  peritonitis. 

The  earlier  the  diagnosis  is  made  and  the  quicker  the  proper 
surgical  treatment  is  applied  in  the  cases  that  are  attended 
with  extravasation  into  the  free  peritoneal  cavity,  the  less  will 
be  the  area  of  peritoneum  which  is  soiled  with  the  septic 
material  and  the  less  will  be  the  likelihood  of  a  diffuse  septic 
peritonitis.  The  aim  should  be  to  establish  a  diagnosis  before 
a  septic  peritonitis  develops,  and  this  is  possible  only  by  a 
careful  study  of  each  individual  case.  When  a  peritonitis 
has  developed  the  diagnosis  is  very  easy,  but  the  patient's 
chances  for  recovery  with  or  without  operative  interference 
is  proportionally  bad. 

Turning  now  to  the  clinical  evidences  of  perforation,  we 
find  that  the  ferjoration,  'per  se,  gives  rise  only  to  local  pain ; 
this  is  of  varying  severity,  being  very  intense  and  tearing  in 
the  acute  cases,  and  so  slight  as  to  pass  unnoticed  in  the 
gradual  ones.  The  pain  may  occasion  some  slight  reflex 
shock  and  reflex  vomiting.  The  other  symptoms  attending 
the  perforation  are  due  entirely  to  the  extravasation  of  septic 
material.  Their  intensity  depends  upon  the  rapidity  with 
which  the  septic  material  escapes  into  the  peritoneal  cavity, 
and  upon  the  area  of  the  peritoneum  which  is  soiled. 

With  sudden  acute  perforations  of  large  size  that  are  not 


276       INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

surrounded  hy  limiting  adhesions,  there  is  a  rapid  extensive 
soiling  of  the  peritoneum.  The  earhest  symptoms  are  those 
of  deep  shock — viz.,  cold,  clammy  skin;  feeble,  rapid  pulse, 
and  subnormal  temperature — and  to  this  the  patient  may 
succumb.  If  he  does  not,  there  rapidly  develops  a  diffuse 
septic  peritonitis,  with  free  gas  in  the  peritoneal  cavity,  the 
evidences  of  which  are  a  rigidity,  hardness,  and  respiratory 
immobility  of  the  abdominal  wall;  an  increasing  dulness  in 
the  flanks,  which  shifts  with  a  change  in  the  patient's  posi- 
tion; an  increasing  abdominal  distention,  a  concentric  oblit- 
eration of  liver  and  splenic  flatness,  general  abdominal  pain 
and  tenderness,  vomiting,  constipation,  and  a  rise  in  the 
pulse  rate  out  of  proportion  to  the  rise  in  temperature.  The 
leukocyte  count  is  not  constant;  it  may  be  normal  or  consid- 
erably increased.  It  is  a  good  prognostic  sign  if  it  is  high, 
but  is  of  no  diagnostic  value. 

With  a  small  pin-hole  perforation  into  the  general  peri- 
toneal cavity  the  leakage  is  very  gradual.  The  initial  shock 
is  much  less  severe,  and  the  development  of  the  symptoms 
of  diffuse  peritonitis  is  much  slower. 

With  perforations  that  have  been  completely  closed  by 
adhesions  before  actual  rupture  occurred,  the  latter  event 
is  attended  only  with  pain,  and  there  are  apt  to  be  no  subse- 
quent evidences. 

With  perforations  in  which  the  extravasation  of  infected 
matter  is  confined  by  limiting  adhesions  to  a  local  area  of  the 
peritoneal  cavity,  or  with  perforations  into  the  retroperitoneal 
cellular  tissue,  the  initial  shock  is  of  moderate  severity,  and 
it  is  followed  by  the  formation  of  a  localized  intraperitoneal 
or  retroperitoneal  or  subphrenic  exudate.  This  occasions 
local  pain  and  a  rise  of  temperature  and  pulse  rate,  local 
abdominal  rigidity  and  immobility,  local  distention,  possibly 
vomiting  and  constipation.  The  leukocyte  count  rises  to 
15,000  or  30,000.  The  physical  signs  are  those  of  an  intra- 
peritoneal or  retroperitoneal  or  subphrenic  abscess,  which 
sometimes  contains  gas. 

To  recapitulate: 
^'Large  perforations  into  the  free  peritoneal  cavity,  which 
are  accompanied  by  extensive  extravasation  of  septic  mate- 
rial, occasion  deep  shock;  whereas,  small  perforations,  which 


PERFORATIONS  INTO    THE   PERITONEAL   CAVITY      277 

are  attended  with  gradual  extravasation  of  infected  matter, 
and  those  that  are  com'pletely  shut  off  from  the  peritoneal 
cavity,  and  therefore  not  attended  with  any  extravasation, 
and  those  in  which  the  extravasation  is  confined  to  a  local 
area,  occasion  little  or  no  shock. 

In  all  there  are  evidences  of  peritonitis.  With  the  cases 
of  perforation  and  extravasation  into  the  free  peritoneal 
cavity,  the  peritonitis  advances  rapidly;  with  those  in  which 
the  extravasation  is  absent  or  confined  to  a  local  portion  of 
the  peritoneal  cavity,  the  peritonitis  usually  remains  local, 
though  progression  is  not  impossible.  The  earliest  symptoms 
of  peritonitis  are  abdominal  rigidity  and  immobility  and 
increased  pulse  rate.  Temperature  elevations  are  usually 
present,  but  they  are  not  in  proportion  to  the  increased  pulse 
rate.  The  leukocyte  count  in  dift'use  peritonitis  may  be  high, 
but  this  is  not  constant.  Its  presence  is  of  good  prognostic 
import.  With  a  sacculated  abscess  the  leukocytes  rise  to 
20,000  or  30,000.     Vomiting  and  distention  appear  late. 


PERFORATIONS  OF  THE  SPECIAL  VISCERA. 

Stomach. — Perforations  of  the  anterior  wall  of  this  vis- 
cus  are  apt  to  be  into  the  free  peritoneal  cavity.  The  extrav- 
asated  material  and  the  subsequent  peritonitis  remain  con- 
fined to  the  upper  quadrant  of  the  abdomen  for  twelve  to 
twenty-four  hours,  their  downward  spread  being  retarded  by 
the  transverse  colon  and  mesocolon.  The  peritonitis  is 
likely  to  be  less  severe  on  account  of  the  diminished  virulence 
of  the  organisms  residing  in  the  stomach.  Perforations  of 
the  posterior  wall  of  the  stomach  are  into  the  bursa  omen- 
talis,  in  which  the  extravasated  material  is  very  apt  to  be 
confined;  though  it  may  subsequently  burrow  upward  into 
the  subphrenic  spaces,  causing  a  subphrenic  abscess. 

Duodenal  Perforations. — If  they  are  on  the  anterior  wall 
of  the  viscus  the  rupture  is  usually  into  the  free  peritoneal 
cavity.  The  extravasated  material  gravitates  along  the  outer 
side  of  the  ascending  colon  into  the  right  iliac  fossa,  and 
gives  rise  to  a  peritonitis  that  appears  to  originate  from  a  dis- 
eased appendix.    If  they  are  on  the  posterior  wall  the  extrav- 


278      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

asation  takes  place  into  the  retrodiiodenal  cellular  tissue;  here 
it  gives  rise  to  an  abscess,  which  may  burrow  upward  to  the 
right  subphrenic  region  or  downward  into  the  iliac  fossa; 
and  in  the  latter  instance  it  may  be  confounded  with  a  retro- 
colic  appendicular  abscess. 

Typhoid  Perforations. — Typhoid  perforations  are,  as  a 
rule,  attended  with  extravasation  into  the  free  peritoneal 
cavity,  and  are  rapidly  followed  by  the  development  of  a 
diffuse  septic  peritonitis;  only  occasionally  are  they  sur- 
rounded by  adhesive  barriers  which  confine  the  extravasated 
material,  and  so  lead  to  the  formation  of  a  local  intraperi- 
toneal abscess.  The  perforated  loop  of  intestine  is  usually 
at  or  near  the  right  iliac  fossa,  and  for  this  reason  the  symp- 
toms resemble  those  of  perforative  appendicitis.  Diagnostic 
errors  are  especially  likely  to  arise  in  the  ambulatory  cases  of 
typhoid. 

Appendicular  Perforations. — ^The  organ  is  usually  sur- 
rounded by  omental  and  intestinal  adhesions  before  the 
actual  perforation  occurs.  These  adhesive  barriers  usually 
confine  the  extravasation  to  the  right  iliac  fossa,  where  an 
abscess  forms.  Sometimes,  however,  the  perforation  is  into 
the  free  peritoneal  cavity  or  into  the  retrocolic  cellular  tis- 
sues; in  the  latter  instance  the  pus  may  burrow  upward  to 
the  liver  and  right  subphrenic  space. 

Other  parts  of  the  intestinal  tract,  the  gall-bladder  and 
bile-ducts,  or  the  urinary  bladder  may  perforate  into  the 
free  peritoneal  cavity  or  into  a  space  that  is  surrounded  by 
limiting  adhesions.  The  accident  occasions  either  a  difi^use 
peritonitis  or  a  local  peritonitis  with  abscess  formation  at  the 
site  of  the  perforation. 

It  is  to  be  noted  that  a  strictly  limited  abscess  may  at  any 
time  rupture  into  the  general  peritoneal  cavity  and  occasion 
a  diffuse  purulent  peritonitis. 

The  diagnosis  of  a  perforation  is  made  by  a  careful  consid- 
eration of  the  patient's  previous  and  present  history  (an  old 
ulcer  or  neoplasm  in  the  gastrointestinal  tract,  or  the  exist- 
ence of  typhoid  fever,  or  of  recurring  attacks  of  appendicitis, 
or  cholecystitis  being  especially  significant),  and  from  a  study 
of  the  symptoms.  The  occurrence  of  shock,  tearing  pain  in 
the   abdomen,   rigidity  of  the   abdominal  wall,   concentric 


PERFORATIONS  INTO   THE  PERITONEAL   CAVITY      279 

obliteration  of  liver  and  splenic  dulness,  with  a  gradually 
rising  pulse  rate,  are  early  and  fairly  conclusive  signs.  The 
development  of  a  diffuse  septic  peritonitis  merely  confirms 
our  early  diagnosis. 

The  viscus  which  is  perforated  is  determined  from  a  con- 
sideration of  the  previous  history;  thus  a  history  of  gastric 
or  duodenal  ulcer,  of  typhoid  fever,  of  previous  attacks  of 
appendicitis,  cholecystitis,  etc.,  is  most  valuable  as  a  guide 
to  the  site  of  the  disease.  A  further  guide  is  afforded  by  the 
fact  that  the  peritonitis  is  always  most  intense  at  its  point  of 
origin. 

Perforations  of  duodenal  ulcers  and  of  typhoid  ulcers, 
especially  in  the  ambulatory  type  of  the  latter  disease,  closely 
resemble  in  their  clinical  manifestations  perforations  of  the 
appendix  vermiformis,  and  they  are  frequently  diagnosti- 
cated as  perforative  appendicitis.  The  error  is  all  the  more 
pardonable  in  cases  of  perforating  duodenal  ulcer  because 
this  sometimes  gives  no  evidence  of  its  presence  until  per- 
foration occurs.  The  cases  of  this  latter  malady  that  do 
give  symptoms  before  perforation  can  be  distinguished  from 
cases  of  appendicitis  by  the  previous  history  of  pain  in  the 
right  hypochondrium  several  hours  after  eating  and  by 
the  absence  of  previous  attacks  of  appendicitis.  The  Widal 
reaction  of  the  blood  and  other  evidences  of  typhoid  fever 
will  distinguish  typhoidal  from  appendicular  perforations. 

Rupture  of  a  hollow  viscus,  infected  cyst,  or  abscess  into 
the  peritoneal  cavity  is  distinguished  from  intestinal  obstruc- 
tion by  the  lack  of  the  absolute  constipation  which  attends 
this  latter  disease,  and  by  the  presence  of  concentric  oblitera- 
tion of  liver  and  splenic  dulness,  and  by  the  history  of  a  cause 
for  the  perforation. 

From  mesenteric  thrombosis  and  embolism  this  condition 
differs,  in  that  the  former  frequently  complicates  cardiac 
and  kidney  disease  and  has  an  acute  onset,  with  little  or  no 
shock,  but  with  one  or  more  bloody  evacuations  from  the 
lower  bowel. 


CHAPTER   XXV. 

INTESTINAL  OBSTRUCTION. 

ACUTE  OBSTRUCTION, 

The  clinical  picture  of  acute  intestinal  obstruction  is  so 
typical  that  its  ready  recognition  is  comparatively  easy.  The 
onset  is  acute,  with  intense  colicky  pain  at  the  site  of  obstruc- 
tion, varying  degree  of  shock,  vomiting,  absolute  constipa- 
tion, and  gradually  increasing  intestinal  distention.  The 
first  vomitus  consists  of  the  contents  of  the  stomach ;  later  on 
it  contains  bile  and  fecal-smelling  material.  It  is  to  be  noted 
that  one  or  two  evacuations  from  the  bowel  frequently  occur 
after  the  onset  of  the  symptoms,  but  these  are  not  to  be  looked 
upon  as  evidence  of  the  patency  of  the  intestinal  lumen;  they 
are  derived  from  the  bowel  below  the  site  of  obstruction,  and 
after  this  has  emptied  itself,  absolute  constipation  is  present. 

When  an  acute  obstruction  is  suspected,  a  high  enema, 
consisting  of  a  quart  of  soapsuds  with  half  an  ounce  of  ox- 
gall and  a  drachm  of  the  spirits  of  turpentine  should  be 
administered,  the  patient  being  placed  in  the  dorsal  recum- 
bent position,  with  the  hips  elevated  on  several  hard  pillows. 
The  enema  to  be  successful  must  be  followed  by  the  passing 
of  foul-smelling  gases  and  fecal  particles.  It  is  to  be  remem- 
bered that  the  first  enema  may  be  attended  with  a  good 
result,  but  that  in  complete  obstructions  subsequent  enemata 
will  prove  absolutely  ineffectual. 

In  incomplete  obstructions  foul  gas  and  blood-stained 
mucus  and  fecal  particles  may  continue  to  be  evacuated  per 
rectum;  in  these  cases  the  diagnosis  must  be  made  from  the 
pain,  the  persistent  vomiting,  and  gradually  increasing  abdom- 
inal distention. 

The  administration  of  a  cathartic  in  suspected  cases  of 
acute  obstruction  is  rarely  advisable,  for  should  there  be 


INTESTINAL  OBSTRUCTION  281 

obstruction  of  the  bowels,  the  symptoms  will  be  materially 
aggravated  thereby. 

The  character  of  the  obstruction,  whether  dynamic  or 
mechanical,  and  the  cause  to  which  it  is  due,  are  to  be  deter- 
mined from  the  anamnesis  and  by  physical  examination.  The 
dynamic  varieties  result  from  a  weakness  or  paralysis  of  the 
muscular  coat  of  the  bowel;  they  occur  with  peritonitis, 
thrombosis,  or  embolism  of  the  mesenteric  vessels  and  as  a 
sequence  to  overdistention  of  the  bowel.  A  temporary 
paretic  condition  occurs  in  conjunction  with  strangulation 
of  the  testicles,  diseases  of  the  pancreas,  after  laparotomy, 
especially  when  the  omentum  has  been  deligated,  and  after 
operations  upon  the  rectum,  etc. 

The  mechanical  varieties  result  from  strangulation  or  obtu- 
ration of  the  bowel,  an  interference  with  the  blood  supply  of 
the  affected  loop  of  intestine  attending  the  stra^ngulation  types. 
Examples  of  the  latter  are  volvulus,  knots,  strangulation  by 
bands,  and  by  normal  or  abnormal  orifices,  etc.;  of  the  obtu- 
rator variety,  examples  are  furnished  by  the  obstruction  from 
foreign  bodies — e.  g.,  gallstones,  by  constricting  or  compress- 
ing neoplasms,  feces,  etc.  The  invagination  of  the  bowel 
represents  a  combination  of  the  strangulation  and  obturation 
types. 

The  cause  of  the  obstruction  can  usually  be  determined 
from  the  previous  history  and  from  a  careful  physical  exami- 
nation. Thus  a  history  of  an  old  peritonitis  or  of  an  inflamma- 
tion of  an  intraperitoneal  organ  suggests  an  obstruction  by  a 
band.  A  previous  hernia  points  to  this  condition  as  a  cause 
of  the  strangulation.  A  sudden  onset  with  bloody  evacuations 
per  rectum,  and  a  previous  history  of  chronic  cardiac  or 
Bright's  disease,  or  diabetes,  suggests  the  possibility  of 
mesenteric  thrombosis  or  embolism.  A  history  of  cholelithia- 
sis, with  a  recent  severe  attack  of  biliary  colic,  suggests  the 
possibility  that  a  gallstone  has  ulcerated  into  the  bowel  and 
is  acting  as  an  obturator.  A  history  of  blood  and  mucous 
evacuations  in  a  child  points  to  intussusception. 

A  hernia  should  always  be  looked  for  when  there  are  evi- 
dences of  obstruction.  A  tense,  suddenly  enlarged,  tender 
swelling  in  the  inguinal, femoral,  or  umbilical  regions  or  other 
weak  part  of  the  abdominal  wall  points  to  a  strangulated 


282      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

hernia.  The  occurrence  of  painful  spasmodic  erections  of 
the  bowel  suggests  a  long-standing  chronic  stenosis  of  the 
bowel  with  a  sudden  complete  obstruction.  A  doughy,  tender, 
movable  tumor  in  the  abdomen,  with  a  history  of  bloody, 
mucous  evacuations,  points  to  acute  intussusception.  Invagi- 
nation may  further  be  recognized  if  the  invaginated  gut  pro- 
trudes at  the  anus,  or  if  it  can  be  palpated  per  rectum.  A 
much  distended,  dull,  tympanitic  tumefaction,  surrounded 
by  coils  of  distended  intestine,  suggests  a  volvulus  of  the 
bowel.  In  peritonitis  the  onset  of  the  obstructive  symptoms 
is  slower :  there  is  a  preceding  history  of  local  intraperitoneal 
inflammation — e.  g.,  appendicitis,  cholecystitis,  pyosalpinx, 
etc. — the  abdomen  is  generally  tender;  there  is  no  peristalsis; 
the  facies  is  drawn  and  anxious,  the  pulse  is  very  rapid,  and 
the  temperature  is  slightly  or  considerably  elevated.  Such  a 
picture  following  upon  an  acute  obstruction  of  the  bowels 
shows  that  a  peritonitis  has  supervened. 

The  Site  of  Obstruction. — Very  early  vomiting  and  one 
or  two  good  fecal  movements,  with  escape  of  flatus  after  the 
onset,  indicate  a  high  site  of  the  obstruction;  whereas,  early 
absolute  constipation  with  late  vomiting  points  to  a  low  site 
of  the  obstructed  bowel.  Meteorism  of  the  central  part  of 
the  abdomen,  with  flattened  flanks,  indicates  an  obstruction 
above  the  ileoca^cal  valve,  and  general  abdominal  distention 
points  to  obstruction  in  the  lower  bowel.  The  caecum  is 
always  very  much  distended  in  obstruction  of  the  colon  dis- 
tally  to  it,  and  forms  a  bulging,  tympanitic  mass.  Very  slight 
abdominal  distention  points  to  obstruction  high  up  in  the 
bowel. 

The  obstructed  coil  can  sometimes  be  palpated;  it  has  a 
greater  resistance  and  less  motion  than  the  other  coils,  and  is 
always  felt  at  the  same  place  at  repeated  examinations.  This 
flxed  position  has  given  it  the  name  of  the  "fixed  loop."  The 
presence  of  a  fixed  loop  helps  to  differentiate  between  obstruc- 
tion and  peritonitis.  In  obstruction  of  the  small  intestine 
indican  appears  early  in  the  urine;  in  obstruction  of  the  large 
bowel  indican  is  absent  from  the  urine  or  appears  late. 

The  mechanical  and  true  paralytic  types  of  acute  intes- 
tinal obstruction  are  distinguished  from  the  paretic  types  by 
the  continuously  progressive  character  of  the  symptoms  that 


INTESTINAL  OBSTRUCTION  283 

attended  them,  the  presence  of  a  fixed  loop  of  bowel,  the 
rapid  deterioration  of  the  general  condition,  and  the  increas- 
ing rapidity  of  the  pulse. 

In  'peritonitis  there  is  a  preceding  history  of  local  intra- 
peritoneal inflammation,  and  there  is  general  abdominal 
tenderness,  rigidity  of  the  abdominal  wall,  a  drawn,  anxious 
appearance,  and  very  rapid  pulse. 

In  the  reflex  paresis  of  the  bowels  accompanying  acute 
and  subacute  pancreatic  disease,  the  general  symptoms  are 
very  much  like  those  of  acute  obstruction.  In  pancreatic 
disease,  however,  the  distention  does  not  become  so  marked, 
there  are  pain  and  tenderness  in  the  epigastrium,  possibly 
sugar  in  the  urine,  and  free  fat  in  the  stools,  and  there  may 
be  a  preceding  history  of  cholelithiasis. 

CHRONIC  OBSTRUCTION. 

With  the  lesser  grades  of  chronic  obstruction  of  the  bowels 
the  symptoms  are  but  slightly  pronounced  and  the  diagnosis 
is  consequently  difficult  to  make.  Attacks  of  colicky  pain, 
with  pronounced  tendency  to  constipation  and  distention  of 
the  bowel,  are  very  suggestive  of  chronic  obstruction  and 
demand  that  we  keep  the  patient  under  careful  observation 
until  the  character  of  the  malady  becomes  clear. 

As  the  obstruction  becomes  more  complete  the  attacks 
of  colicky  pain  become  more  severe  and  more  frequent,  and 
in  conjunction  with  them  occur  visible  or  palpable  erections 
of  the  bowel  above  the  seat  of  obstruction.  These  painful 
intestinal  erections  are  pathognomonic  of  the  condition. 
Coincidently  the  constipation  becomes  more  marked,  but 
sometimes  it  alternates  with  a  watery  mucous  diarrhoea,  the 
latter  being  due  to  a  catarrhal  enteritis  or  colitis  set  up  by  the 
irritating  fecal  matter  which  is  retained  above  the  site  of 
the  obstruction.  If  at  any  time  the  stenosed  orifice  becomes 
totally  occluded  by  swelling  or  by  the  lodgement  of  a  foreign 
body  within  it,  the  signs  of  an  acute  obstruction  would  be 
manifest. 

Physical  examination  and  the  previous  history  of  the 
patient  frequently  help  to  determine  the  cause  and  site  of  the 
obstruction. 


284      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

Cachexia,  diminution  of  hsemoglobin  to  30  per  cent,  or 
40  per  cent.,  marked  loss  of  weight,  and  the  presence  of 
tumor  particles  in  the  stools  point  to  cancer  of  the  wall  of  the 
bowel,  which  the  presence  of  a  hard,  nodular,  fixed  tumor 
confirms. 

Persistent  constipation  and  hard  feces,  with  no  deteriora- 
tion in  general  health,  or  diminution  of  haemoglobin  per- 
centage, and  no  cachexia,  point  rather  to  impacted  feces;  a 
diagnosis  that  is  confirmed  by  the  presence  of  hardened  feces 
in  the  rectum  or  a  soft,  indentable  tumor  of  the  intestine. 

A  previous  peritonitis  suggests  compression  of  the  intestine 
by  a  band. 

An  elongated,  sausage-shaped  tumor,  which  is  not  very 
tender,  but  is  soft  and  elastic,  in  conjunction  with  mucous 
stools,  suggests  a  chronic  intussusception. 

Moderately  marked  symptoms  of  stenosis,  with  a  hard, 
irregular,  sausage-shaped,  tender,  adherent  tumor  in  the 
ileocEecal  regions,  suggests  tuberculosis;  the  diagnosis  is 
verified  by  the  presence  of  other  foci  of  tuberculosis  and  by 
a  positive  tuberculin  test. 

Very  chronic  stenotic  symptoms,  with  an  ileocsecal  tumor 
that  is  adherent  to  the  iliac  wall,  fixed,  not  tender,  hard,  with 
spots  of  softening,  point  to  actinomycosis  of  the  bowels. 

Site  of  Obstruction. — The  site  of  obstruction  is  deter- 
mined in  the  same  way  as  in  the  acute  obstruction.  (See  p. 
282.)  It  is  to  be  noted  that  obstruction  of  the  large  intestine 
below  the  caecum  is  accompanied  by  considerable  distention 
of  the  csecum. 


CHAPTER   XXVI. 
DISEASES  OF  THE  APPENDIX  VERMIFORMIS. 

The  appendix  usually  lies  in  the  right  iliac  fossa,  its  base 
corresponding  to  the  mid-point  of  a  line  drawn  from  the 
superior  iliac  spine  to  the  umbilicus  (McBurney's  point). 
Occasionally  it  lies  in  the  pelvis,  and  sometimes,  either 
because  of  a  long  mesenteriolum  or  a  very  freely  movable 
caput  coli,  it  lies  in  the  left  iliac  fossa. 

The  appendix  can  be  best  palpated  when  the  patient  is  in 
the  dorsal  recumbent  position.  By  having  the  patient  slightly 
raise  the  extended  right  lower  limb  from  the  plane  of  the 
examining  table  or  bed  (see  Fig.  118),  thereby  contracting 
the  psoas  muscle,  the  appendix  and  caput  coli  are  brought 
nearer  to  the  anterior  abdominal  wall  and  their  palpation  is 
thereby  rendered  more  accurate  and  easy.  If  the  appendix 
lies  in  the  pelvis,  it  is  best  palpated  through  the  rectum  or 
vagina. 

The  diagnosis  of  diseased  conditions  of  the  appendix 
vermiformis  is  in  most  instances  readily  and  easily  made,  and 
yet  it  is  no  exaggeration  to  say  that  more  diagnostic  errors 
are  committed  in  the  name  of  this  organ  than  in  that  of  any 
of  the  other  abdominal  viscera.  This  is  partly  due  to  the 
close  anatomical  proximity  of  the  appendix  to  the  uterine 
appendages,  the  right  ureter  and  kidney,  and  in  some  cases 
the  gall-bladder,  and  partly  to  the  similarity  of  the  clinical 
manifestations  of  its  diseased  conditions  to  those  which  are 
due  to  affections  of  the  pancreas,  duodenum,  diaphragmatic 
pleura,  etc. 

The  most  important  symptoms  of  an  acute  attack  of  ap- 
pendicitis are  crampy,  abdominal  pain  which  becomes  local- 
ized in  the  right  iliac  fossa  (rarely  in  the  pelvis  or  left  iliac 
region),  one  or  more  attacks  of  vomiting,  constipation  (some- 
times diarrhoea),  fever,  increased    frequency  of  the  pulse. 


286      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

tenderness  at  the  site  of  the  diseased  appendix  (most  fre- 
quently in  the  right  ihac  fossa,  bnt  sometimes  in  the  pelvis,  or 
left  iliac  fossa  or  right  hypochondrium),  rigidity  of  the  ab- 
dominal wall  overlying  the  inflamed  organ,  and  often  a  tume- 
faction or  swelling  at  the  appendicular  site.  From  these 
manifestations  the  diagnosis  of  an  attack  of  appendicitis 
can  usually  be  made,  and  by  a  carefully  taken  anamnesis, 
with  a  thorough  and  complete  abdominal  and  thoracic  exam- 
ination, in  which  we  should  always  include  a  rectal  and  vag- 
inal palpation,  we  shall  be  enabled  to  exclude  or  confirm 
the  presence  of  diseased  conditions  of  other  abdominal  or 
thoracic  organs  that  may  simulate  appendicitis.  There  is, 
however,  a  small  proportion  of  cases  in  which  it  is  impos- 
sible to  differentiate  between  disease  of  the  appendix  and 
that  of  other  right-sided  abdominal  organs ;  in  such  cases  the 
important  point  to  decide  during  an  acute  stage  of  inflam- 
mation is  whether  or  not  operative  interference  is  urgently 
demanded.^  If  so,  the  abdominal  incision  will  clear  up  the 
diagnosis.  If,  however,  delay  can  be  safely  practised,  further 
and  continued  observation  will,  as  a  rule,  throw  light  upon 
the  nature  and  site  of  the  disease. 

If  it  is  impossible  to  determine  in  all  acute  cases  whether 
or  not  the  appendix  is  at  the  root  of  or  is  concerned  in  an 
inflammatory  process  on  the  right  side  of  the  abdomen,  much 
less  is  it  always  possible  to  determine  from  the  clinical  evi- 
dences the  exact  character  of  the  lesions  that  are  present  in 
the  diseased  organ.  Those  who  insist  upon  immediate  oper- 
ation in  all  acute  cases  of  appendicitis  advance  this  inability 
to  determine  the  nature  of  the  lesions  within  an  inflamed 
appendix  as  a  cause  for  their  practice.  But  while  it  must  be 
confessed  that  it  is  not  always  possible  to  accurately  state 
what  are  the  pathological  changes  in  the  inflamed  appendix, 
we  are  concerned  in  forming  our  decision  for  or  against  imme- 
diate operation,  not  so  much  in  the  pathological  alterations 
which  the  diseased  appendix  has  undergone,  as  we  are  in  the 

1  The  urgency  of  operative  interference  is  determined  from  the  rapidity  of  the 
pulse,  the  general  appearance  of  the  patient,  the  abdominal  rigidity,  and  from  the 
history  of  the  onset  and  course  of  the  attack.  A  rising  pulse  rate  to  110,  then  to  120 
and  over,  an  anxious  expression  and  increasing  abdominal  rigidity,  Irrespective  of 
the  temperature  elevations,  speak  for  immediate  operation,    (See  p.  287.) 


DISEASES  OF   THE  APPENDIX   VERMIFORMIS       287 

severity  of  the  inflammation;  and  while  we  cannot  predict 
from  the  cHnical  signs  what  will  be  the  severity,  we  can,  in 
the  vast  majority  of  cases,  tell  what  is  the  severity  at  a  par- 
ticular time.  If,  therefore,  we  keep  a  sharp  and  close  watch 
of  the  patient  we  will  be  able  to  determine  when  compli- 
cations arise  and  whether  the  inflammation  is  progressive  or 
regressive  in  character,  and  upon  this  determination  we  can 
base  our  decision  for  or  against  immediate  operation. 

The  severity  of  the  inflammation  is  judged  from  the  char- 
acter of  the  onset  of  the  attack,  its  subsequent  course,  and 
from  the  rapidity  of  the  pulse  rate,  the  rigidity  of  the  abdominal 
wall,  and  general  appearance  of  the  patient.  Its  progression 
is  determined  by  observing  the  pulse  rate,  the  abdominal 
rigidity,  and  the  general  condition  of  the  patient. 

An  anxious,  drawn  expression  is  always  a  sign  of  serious 
disease  of  the  appendix.  An  hourly  increasing  pulse  rate, 
even  though  the  temperatures  are  normal  or  slightly  ele- 
vated, is  a  most  important  indication  of  a  rapidly  progressive 
severe  inflammation  of  this  organ.  Marked  abdominal 
rigidity  is  likewise  a  valuable  indication  of  a  severe  inflam- 
matory condition.  A  sudden  onset  with  a  chill,  high  temper- 
ature, and  rapid  pulse  rate,  with  sudden  abatement,  points 
to  a  sudden  diminution  of  high  tension  within  the  appendix. 
This  may  be  due  to  a  re-establishment  of  the  patency  of  the 
orifice  of  exit  of  the  appendicular  canal — e.  g.,  by  the  expul- 
sion of  a  foreign  body,  or  it  may  be  due  to  perforation  or 
gangrene  of  the  appendix,  the  latter  being  much  the  more 
frequent. 

An  onset  with  severe  chill,  and  one  or  more  subsequent 
chills,  irrespective  of  the  local  conditions,  but  especially  if 
no  abscess  is  present,  strongly  suggests  the  possibility  of  an 
infected  mesenteric  thrombosis  and  septicopysemia. 

A  very  rapid  pulse  rate,  with  slightly  elevated  temperature, 
persistent  vomiting  of  brownish  material,  with  marked  pros- 
tration and  feeling  of  well-being,  points  to  a  septicaemia. 

A  severe  chill,  increasing  pulse  rate,  and  marked  abdom- 
inal rigidity,  with  or  without  temperature  elevation,  or  the 
presence  of  a  mass  in  the  appendicular  region,  speak  strongly 
for  immediate  operation. 

But  while  the  exact  character  of  the  lesions  in  the  diseased 


288      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

appendix  cannot  be  accurately  determined  in  each  case, 
there  is  a  cHnical  picture  that  usually  goes  with  definite 
lesions  of  the  diseased  organ,  and  from  such  clinical  picture 
we  can  form  a  working  estimate  of  the  character  of  the 
inflammatory  process. 


ACUTE  AND  CHRONIC  FOLLICULAR  APPENDICITIS. 

With  acute  follicular  (catarrhal)  appendicitis  the  symp- 
toms are  not  very  severe.  The  onset  is  sudden,  with  or  with- 
out a  chill,  the  temperature  rising  to  between  99°  and  103° 
per  rectum,  the  pulse  rate  rarely  rising  above  100  to  the 
minute.  At  first  there  are  crampy  pains  around  the  umbilicus, 
but  after  a  few  hours  these  localize  in  the  right  iliac  fossa. 
The  patient  may  vomit  or  be  constipated  or  have  diarrhoea. 
The  abdominal  wall  in  the  right  iliac  region  is  somewhat 
rigid,  and  there  is  distinct  tenderness  over  the  appendix.^ 

The  leukocytes  are  not  materially  increased  in  number. 
The  attack  subsides  within  twenty-four  hours  to  several 
days  or  a  week,  and  during  it  the  patient  is  usually  confined 
to  bed.  With  the  severe  grades  of  this  type  of  appendicitis, 
a  slight  local  peritonitis,  with  formation  of  adhesions,  de- 
velops. The  first  attack  does  not,  as  a  rule,  produce  organic 
changes  in  the  walls  of  the  appendix,  but  succeeding  attacks 
usually  leave  them  thickened  and  infiltrated,  thus  resulting 
in  a  chronic  follicular  (catarrhal)  appendicitis.  This  mani- 
fests itself  by  recurring  acute  seizures  in  the  intervals  be- 
tween which  the  appendix  is  quite  tender  and  thickened.  If 
adhesions  have  formed,  there  is  a  tumefaction  around  the 
appendix. 

1  If  the  appendix  is  situated  in  the  right  iliac  fossa  the  tenderness  will  very  liliely 
be  at  McBurney's  point,  but  if  it  is  in  the  pelvis  or  on  the  left  side  of  the  abdomen, 
or  behind  the  caecum  the  tenderness  will  be  at  the  corresponding  site. 


DISEASES  OF   THE  APPENDIX   VERMIFORMIS       289 


ACUTE  ULCERATIVE  AND  GANGRENOUS  APPENDICITIS. 

With  acute  ulcerative  or  gangrenous  appendicitis^  without 
perforation  the  onset  is  usually  sudden;  there  may  or  may 
not  have  been  previous  attacks  of  follicular  appendicitis. 
There  is  an  initial  chill  or  chilly  sensations;  the  temperature 
rises  to  102°  or  104°;  the  pulse  rate  varies  between  90  and 
120  or  over.  There  is  vomiting,  constipation,  or  diarrhoea. 
Locally  there  is  considerable  pain  and  tenderness  over  the 
appendix,  and  marked  localized  abdominal  rigidity.  The 
leukocytes  are  not  regularly  or  persistently  increased.  The 
attack  may  subside  within  several  days  to  a  week,  and  during 
it  the  patient  is  quite  sick;  or  the  inflammation  goes  on  to 
perforation  and  to  the  development  of  other  complications. 

With  acute  ulcerative  or  gangrenous  appendicitis  with  per- 
foration the  attack  commences  just  as  the  preceding  one. 
After  one  to  several  days  perforation  occurs,  at  which  time 
there  is  a  sudden  abatement  in  the  local  and  general  symp- 
toms. This  relief,  however,  is  very  shortly  followed  by 
another  train  of  symptoms,  which  vary  according  to  whether 
the  extravasation  of  the  appendicular  contents  into  the  peri- 
toneal cavity  which  follows  upon  the  perforation  is  confined 
or  not  by  limiting  adhesions. 

If  the  extravasation  remains  confined,  a  local  abscess  forms 
around  the  perforated  appendix.^  Such  an  abscess  may  be 
located  in  the  right  iliac  fossa,  or  behind  the  colon,  even 
extending  upward  to  the  liver  and  subphrenic  space,  or  in 
the  pelvis  or  in  the  left  iliac  fossa.  It  forms  a  smooth,  rounded 
swelling  that  usually  has  no  mobility,  and  the  soft  parts  over- 
lying it  are  rigid,  tender,  and  painful.  If  it  lies  in  contact  with 
the  abdominal  wall,  the  percussion  note  over  it  is  dull ;  but  if 

1  Gangrene  occurring  early  in  the  course  of  an  attack  is  usually  due  to  an  interfer- 
ence with  the  vascular  supply  of  the  organ— e.  g.,  by  volvulus  or  kink  of  the  mesen- 
tery, or  by  embolism  or  thrombosis  of  its  nutrient  vessels;  occurring  late,  it  is  due  to 
the  intensity  of  the  inflammatory  process.  It  may  be  confined  to  one  or  more  local 
spots  of  the  mucous  membrane,  or  it  may  involve  the  entire  wall  of  the  organ. 

2  It  is  to  be  especially  noted  that  a  local  abscess  sometimes  forms  without  perfora- 
tion or  without  gangrene  of  the  appendix,  and  that  there  is  no  way  in  which  we  can 
tell  prior  to  operation  whether  the  abscess  is  or  is  not  due  to  gangrene  or  perforation 
of  the  organ. 

19 


290      INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

it  lies  behind  or  between  the  coils  of  intestines,  the  percussion 
note  over  it  is  tympanitic.  If  it  lies  in  the  pelvis  a  bulging, 
tender,  painful  swelling,  more  or  less  distinctly  fluctuating, 
can  be  felt  through  the  vagina  or  rectum.  After  the  formation 
of  the  abscess  the  temperature  varies  between  101°  and  104°, 
the  pulse  is  usually  below  120,  and  the  leukocyte  count  is 
high,  20,000  to  30,000;  occasionally  there  is  vomiting,  and  the 
bowels  are  usually  constipated.  If  the  abscess  is  not  incised 
and  drained,  spontaneous  rupture  into  a  hollow  viscus  or 
into  the  free  peritoneal  cavity  usually  takes  place.  If  the 
rupture  has  occurred  into  a  hollow  viscus,  the  pus  is  dis- 
charged through  this  channel;  if  into  the  peritoneal  cavity, 
a  diffuse  peritonitis  results. 

If  the  extravasation  of  appendicular  contents  following 
upon  the  perforation  takes  place  into  the  free  peritoneal 
cavity,  its  immediate  manifestation  is  shock  of  varying 
severity.  A  diffuse  purulent  peritonitis  soon  develops,  which 
gives  the  following  symptoms:  The  pulse  rate  rises  rapidly 
(to  above  120),  the  temperature  becomes  slightly  or  con- 
siderably elevated  (to  104°  or  105°) ;  the  expression  is  drawn 
and  anxious;  there  is  vomiting  of  gastric,  or  bilious,  or  fecal 
material,  and  obstinate  constipation.  The  leukocyte  count 
is  either  low  or  high.  (High  temperatures  and  high  leukocyte 
count  are  favorable  prognostic  signs,  but  are  of  no  help  in 
diagnosis.)  Locally  the  abdominal  wall  is  tender  and  rigid; 
there  is  gradually  increasing  distention,  absence  of  peristalsis, 
and  a  free,  shifting  exudate  in  the  loins.  The  exudate  may 
become  encapsulated  in  various  and  multiple  regions  of  the 
peritoneal  cavity,  thus  giving  rise  to  irregular  areas  of  dulness 
in  the  abdomen. 


SEPTIC -ffiMIA  AND  SEPTICOPY.ffiMIA  FOLLOWING 
APPENDICITIS. 

Acute  follicular,  or  ulcerative,  or  gangrenous  appendicitis 
may  be  followed  early  or  late  in  the  attack  by  acute  septi- 
csemia  or  by  septic  thrombosis  of  the  venous  radicles  of  the 
appendicular  mesentery.  The  thrombosis  may  remain  local- 
ized in  the  appendicular  mesenteric  veins  or  it  may  extend 


DISEASES   OF   THE   APPENDIX    VERMIFORMIS       291 

upward  into  the  superior  mesenteric  vein,  portal  vein,  and 
liver.  In  the  liver  multiple  abscesses  may  develop  from  the 
lodgement  of  minute  septic  emboli  derived  from  the  disorgan- 
ization of  septic  blood  clots  in  the  mesenteric  and  portal 
veins  (septicopyaemia). 

Such  involvement  of  the  vascular  system  is  especially 
likely  to  occur  when  the  tension  of  the  confined  septic  con- 
tents in  the  appendix  becomes  excessively  high.  Under  these 
conditions  the  slightest  variation,  especially  a  further  increase 
of  pressure,  either  by  vomiting  or  by  the  manipulations  of 
the  surgeon,  may  precipitate  an  injection  of  infectious  and 
toxic  material  into  the  blood  stream,  causing  toxaemia  and 
bacterisemia.  Such  a  septicaemia  may  result  fatally  before 
the  local  changes  in  the  appendix  have  had  time  to  become 
manifest.  The  slower  the  rise  in  tension  the  more  apt  are  the 
bloodvessels  to  be  shut  off  by  the  inflammatory  processes,  and 
consequently  the  less  are  the  dangers  of  acute  septicaemia. 
In  making  the  prognosis  in  a  case  of  acute  appendicitis  the 
surgeon  should  bear  in  mind  that  in  a  foudroyant  case  a 
general  infection  may  have  taken  place  before  his  arrival,  or  be 
precipitated  by  his  manipulations.  With  such  a  bacteriai'mia 
the  patient  is  much  sicker;  he  usually  has  had  a  severe  chill; 
the  pulse  is  especially  rapid,  120  or  over;  the  temperature 
is  not  much  elevated.  The  leukocyte  count  is  apt  to  be  low. 
Locally  there  are  pain  and  tenderness  and  abdominal  rigidity 
at  the  appendicular  site.  No  mass  or  only  a  thickened 
appendix  is  to  be  felt. 

Besides  this  immediate  blood  infection  there  is  the  throm- 
bosis of  the  venous  radicles  of  the  appendicular  mesen- 
teriolum.  Either  from  an  extension  of  the  inflammation 
within  the  appendix  to  the  vascular  structures,  or  from  a 
volvulus  of  the  appendix  and  its  mesenteriolum,  a  throm- 
bosis of  the  venous  radicles  results,  which  necessarily  implies, 
especially  if  the  thrombus  is  an  infected  one,  the  possibility 
of  metastatic  lodgement  of  portions  of  this  thrombus  in  the 
portal  vein,  liver,  and  other  organs.^  Such  a  thrombosis  of 
the    mesenteriolum    may    be    markedly   in    evidence,    even 


1  The  lodgement  in  other  organs  than  the  liver  is  possible  only  when  there  is  a  com- 
mjinication  between  the  portal  and  hepatic  veins, 


292       INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

though  the  appendix  is  neither  gangrenous  nor  perforated. 
If  the  thrombosis  remains  locahzed  in  the  appendicular 
mesenteric  veins,  no  additional  symptoms  from  this  are  mani- 
fest ;  but  if  it  spreads  and  gives  origin  to  a  metastatic  lodge- 
ment of  infected  emboli  in  the  superior  mesenteric  or  portal 
veins,  or  liver,  there  develop  the  symptoms  of  septicopyeemia 
—i.  e.,  repeated  chills,  temperatures  fluctuating  between 
subnormal  and  107°  or  108°,  gradually  increasing  pulse  rate, 
rapid  deterioration  in  general  condition,  and  increasing 
icterus.  The  abdomen  is  flat,  not  tender  or  painful  or  rigid. 
The  liver  is  enlarged  and  somewhat  tender.  The  appetite  may 
continue  good,  and  the  bowels  may  move  regularly.  Death 
from  exhaustion  and  sepsis  occurs  in  from  several  days  to 
several  months.  The  removal  of  the  appendix  after  infective 
thrombosis  has  taken  place  has  no  influence  upon  the  subse- 
quent course  of  the  disease. 

An  ajp'pendicitis  may  be  simulated  by  intestinal  colic, 
enteritis,  cholecystitis,  acute  pancreatitis,  displaced  and  dis- 
eased conditions  of  the  kidneys,  pedunculated  ovarian  and 
uterine  tumors,  tumors  of  the  small  intestine  and  caput  coli, 
and  diseases  of  the  ureter;  also  by  perforations  of  the  stom^ach, 
duodenum,  and  typhoid  ulcers  of  the  intestine  and  by  dia- 
phragmatic pleurisy. 

In  intestinal  colic  the  pulse  rate  is  not  materially  increased; 
there  is  no  abdominal  rigidity,  and  the  appendicular  region 
is  not  sensitive;  high  enemata  relieve  the  pain. 

In  enteritis  there  is  no  appendicular  pain,  no  material 
elevation  of  the  pulse  rate,  and  the  stools  usually  contain 
mucus  and  blood. 

Cholecystitis  is  usually  distinguished  by  a  history  of  pre- 
vious attacks  of  biliary  colic,  the  pain  in  which  radiates  into 
the  back  and  right  shoulder;  some  of  these  attacks  may  have 
been  followed  by  jaundice  and  by  the  passage  of  calculi  in 
the  stools.  A  distended  gall-bladder  that  has  a  long  mesen- 
tery may  occupy  the  right  iliac  fossa  and  so  simulate  an 
appendicular  abscess  or  exudate,  but  the  tumor  caused  by 
such  a  distended  gall-bladder  is  smooth  and  rounded,  and  is 
apt  to  be  quite  movable  from  side  to  side  and  with  respira- 
tion. If  the  examiner  stands  on  the  right  side  of  the  patient, 
facing  his  feet,  and  palpates  the  under  surface  of  the  liver 


DISEASES  OF   THE  APPENDIX   VERMIFORMIS       293 

and  neck  of  the  gall-bladder,  the  smooth,  rounded  tumor 
formed  by  diseased  conditions  of  the  latter  organ  can  be 
traced  downward  from  the  liver.  Distention  of  the  colon 
causes  a  tumor  which  represents  the  gall-bladder  to  move 
upward. 

Acute  'pa7icreatitis  is  marked  by  a  greater  initial  prostra- 
tion, and  possibly  by  a  preceding  history  of  gallstone  disease. 
With  this  malady  the  pain  and  tenderness,  and  possibly  swell- 
ing, are  especially  marked  above  the  umbilicus;  the  urine 
sometimes  contains  sugar  and  the  stools  free  fat.  It  is  often 
impossible  to  make  a  differential  diagnosis,  and  if  on  open- 
ing the  abdomen  the  appendix  is  found  to  be  healthy,  the  pan- 
creas should  always  be  palpated  and  fat  necrosis  looked  for. 

In  displaced  kidney  the  kidney-shaped  tumor  can  always 
be  replaced  into  the  loin;  there  may  be  a  history  of  periodical 
attacks  of  hydronephrosis. 

With  pyelitis,  pyonephrosis,  hydronephrosis,  stone  or  kink 
in  the  ureter  there  is  a  preceding  history  of  cystitis  or  kidney 
colic  ;^  there  are  pathological  changes  in  the  urine,  and  the 
cystoscope  reveals  changes  in  the  ureteral  mouth.  With 
diseased  conditions  of  the  ureter  there  is  always  a  preceding 
cause  for  the  inflammation — e.  g.,  cystitis,  diseased  kidney, 
stone,  etc. — and  the  ureter  can  be  palpated  through  the  abdo- 
men, vagina,  or  rectum  as  a  thickened  cord  passing  from  the 
kidney  to  the  bladder;  the  cystoscope  also  reveals  changes 
in  the  ureteral  orifice. 

A  kidney  colic  may  very  strongly  resemble  an  appendicu- 
lar colic,  and  many  an  appendix  has  been  removed  when 
the  kidney  was  really  the  cause  of  the  trouble.  In  all  cases, 
therefore,  in  which  there  are  no  physical  evidences  that  con- 
clusively point  to  disease  of  the  appendix  the  possibility  of 
a  diseased  kidney  or  of  a  stone  in  the  kidney  or  ureter  being 
the  cause  of  the  pain  and  other  symptoms  should  be  remem- 
bered. The  aid  of  the  x-ray,  cystoscope,  and  ureteral 
catheter,  with  separation  and  careful  examination  of  the  in- 
dividual urines,  should  be  invoked  in  all  such  cases  in  order 
to  ascertain  the  location  and  character  of  the  malady. 

1  In  kidney  colic  the  pain  radiates  to  the  groin,  testicle,  or  ovary,  thereby  differing 
from  the  site  of  the  pain  in  appendicular  disease. 


294      INJURIES  AND   DISEASES  OF   THE   ABDOMEN 

Pedunculated  ovarian  and  uterine  tumors  are,  as  a  rule, 
to  be  differentiated  from  appendicular  exudates  and  ab- 
scesses bv  vaginal  and  rectal  examination.  The  cysts  with 
flabby  walls  are  the  most  difficult  to  palpate.  A  history  of 
menstrual  irregularities  should  excite  our  suspicion  of  ovarian 
or  tubal  or  uterine  disease  or  neoplasm  being  present. 

Diseased  conditions  of  the  right  Fallopian  tube  sometimes 
resemble  very  strongly  diseased  conditions  of  the  appendix. 
A  history  of  genital  infection,  with  the  presence  of  an  en- 
larged and  tender  left  tube,  and  the  close  proximity  of  the 
inflammatory  mass  to  the  uterus  are  in  favor  of  the  trouble 
being  a  pyosalpinx.  A  history  of  menstrual  irregularity 
(see  p.  351),  together  with  colicky  pelvic  pain,  which  is 
possibly  accompanied  with  fainting  spells,  the  early  signs 
of  pregnancy,  and  the  presence  of  a  tender,  soft,  doughy 
tumor  that  is  closely  related  to  the  uterus,  speak  for  extra- 
uterine pregnancy. 

Perforating  ulcers  of  the  stomach  and  duodenum  are 
usually  preceded  by  a  long  history  of  epigastric  pain,  heart- 
burn, eructations,  and  vomiting  of  acid  material,  and  some- 
times by  hsematemesis  and  melsena.  At  the  time  of  perfora- 
tion the  pain  is  of  a  tearing  character  and  is  located  in  the 
epigastrium,  and  only  later  does  it  become  located  in  the 
right  iliac  fossa.  Duodenal  ulcers  sometimes  give  no  evi- 
dences of  their  presence  until  perforation  occurs.  In  such 
cases  the  location  of  the  tearing  pain  in  the  epigastric  or 
hypochondriac  regions  at  the  beginning  of  the  trouble  should 
excite  our  suspicions  of  perforating  duodenal  ulceration. 

Diaphragmatic  pleurisy  is  readily  detected  from  the  fric- 
tion sounds  which  are  to  be  heard  over  the  base  of  the  chest. 
It  should  be  an  invariable  practice  to  carefully  examine  the 
base  of  the  right  chest  in  every  case  in  which  there  is  pain 
in  the  right  iliac  fossa.  If  this  is  religiously  done  the  diag- 
nosis of  appendicitis  will  not  be  made  when  the  patient 
really  has  a  right  basal  pneumonia. 

One  should  further  remember  to  exclude  neuralgia  of  the 
ilioinguinal  nerve  in  cases  where  the  diagnosis  of  appen- 
dicitis is  not  absolutely  positive.  Such  neuralgia  provokes 
pain  in  the  area  supplied  by  this  nerve  which  roughly  corre- 
sponds to  the  iliac  region,  and  may  in  this  respect  resemble 


DISEASES  OF   THE  APPENDIX   VERMIFORMIS       295 

appendicular  disease.  This  ailment  is  especially  likely  to 
be  occasioned  by  a  lateral  curvature  of  the  spine,  and  it  is 
in  patients  with  this  deformity  that  we  should  especially 
be  on  our  guard.  Continued  observation  and  relief  from 
pain  which  is  experienced  by  the  proper  orthopaedic  appa- 
ratus for  the  spinal  deformity  will  enable  us  to  make  the 
correct  diagnosis. 

Sarcoma,  tuberculosis,  actinomycosis,  and  carcinoma  of  the 
intestines  are  often  very  difficult  to  differentiate  from  a  chronic 
diseased  appendix  that  is  surrounded  by  an  exudate  and 
adhesions.  The  presence  of  multiple  tumors,  the  long 
duration  of  the  disease,  and  the  absence  of  a  high  leukocyte 
count  speak  in  favor  of  the  former.  If  an  abscess  has  formed 
secondarily  to  these  affections,  the  incision  of  the  abdomen 
alone  can  clear  up  the  diagnosis. 

Perforating  typhoid  ulcers,  especially  in  the  ambulatory 
type  of  the  disease,  bear  a  close  similarity  to  appendicular 
perforation.  A  preceding  history  of  fever  with  an  enlarged 
spleen,  roseola,  and  Widal  reaction  makes  a  differential 
diagnosis  very  easy,  but  these  symptoms  and  signs  are  not 
always  present.  During  the  typhoid  season  it  is  always 
well  to  have  in  mind  the  possibility  that  a  perforating  ulcer 
may  be  the  cause  for  symptoms  that  simulate  appendicitis, 
and  in  every  case  of  this  latter  malady  we  should  look  for 
evidences  of  typhoid  fever.  The  possibility  of  the  perfo- 
rating ulcer  in  typhoid  being  located  in  the  appendix  should 
not  be  forgotten. 


CHAPTER  XXVIL 

NEOPLASMS  OF  THE  INTESTINE,  MESENTERY,  AND 
OMENTUM. 

NEOPLASMS  OF  THE  INTESTINE. 

Benign  Neoplasms. — A  benign  neoplasm  of  the  bowel  gives 
rise  to.  no  symptoms  beyond  the  presence  of  a  palpable 
tumor  unless  it  occasions  obturation  or  invagination  of  the 
affected  coil  of  intestine  with  resulting  intestinal  obstruc- 
tion. The  tumor  varies  in  size  from  a  walnut  to  an  orange, 
grows  very  slowly,  and  causes  no  disturbances  in  the  gen- 
eral health  of  the  patient.  Histologically  these  benign  tumors 
belong  to  the  lipoma,  myoma,  or  adenoma  groups,  the  myoma 
being  at  times  mistaken  for  sarcoma,  from  which,  however, 
the  slow  growth  and  continued  well-being  of  the  patient 
differentiate  it. 

Malignant  Neoplasms. — Rapid  growth  and  rapid  loss 
of  flesh  and  strength  distinguish  the  malignant  neoplasms  of 
the  intestine.  The  sarcomata  occur  frequently  during  young 
adult  life  as  multiple  tumors,  and  spread  rapidly  to  the 
mesentery  and  omentum.  They  differ  from  the  carcinomata 
in  one  very  essential  particular  in  that  they  do  not  fre- 
quently occlude  the  lumen  of  the  intestine,  and  hence  do  not 
occasion  a  chronic  intestinal  stenosis.  Their  disintegration 
gives  rise  to  moderate  temperature  elevations  between  101° 
and  102°.  The  presence  of  one  of  these  tender,  somewhat 
painful  tumors  in  the  right  iliac  fossa,  together  with  tem- 
perature elevations  and  a  free  ascitic  exudate  in  the  peritoneal 
cavity,  may  lead  one  to  the  impression  that  he  is  dealing 
with  a  subacute  appendicular  exudate.  The  presence  of 
multiple  tumors  within  the  abdomen  which  are  often  to  be 
best  palpated  through  the  rectum,  the  wretched  general  con- 
dition of  the  patient,  the  history  of  the  course  of  the  disease 


NEOPLASMS  OF   THE  INTESTINE  297 

(appendicitis  having  an  acute  onset  with  possible  previous 
attacks) J  and  a  low  leukocyte  count  point  very  strongly  to 
malignant  disease  of  the  bowel. 

The  carcinomata  occur  usually  in  late  adult  life  and  are 
most  frequently  located  in  the  large  intestine,  especially  in 
the  sigmoid  flexure  and  rectum.  They  tend  to  spread  in  an 
annular  fashion  around  the  intestine  and  thus  occasion  a 
chronic  intestinal  stenosis,  the  clinical  signs  of  which  have 
already  been  described  (p.  283).  A  palpable  tumor  is 
usually  a  late  manifestation  of  the  disease,  and  in  some 
instances — e.  g.,  when  the  neoplasm  is  located  at  the  hepatic 
or  splenic  flexure — it  is  never  to  be  felt.  It  is  hard,  irregular, 
nodular,  and  tender,  and  enjoys  some  mobility  until  it  be- 
comes adherent,  which  often  occurs  very  early.  In  most 
instances  a  gradually  increasing  intestinal  stenosis  with  in- 
testinal erections,  and  fetid,  bloody,  purulent,  mucous  stools 
are  the  clinical  evidences  to  which  this  malady  gives  rise. 
In  some  cases,  however,  especially  in  scirrhous  carcinoma  of 
the  sigmoid  flexure,  the  first  indication  which  the  neoplasm 
affords  is  an  acute  intestinal  obstruction,  and  in  others  an 
increasing  otherwise  unexplainable  cachexia  first  suggests  the 
possibility  of  an  intestinal  carcinoma. 

Tuberculosis  and  actinomycosis  of  the  ileocsecal  region 
are  distinguished  from  malignant  disease  by  their  more 
chronic  course.  The  tumor  which  they  occasion  is  not  so 
hard,  and  is  very  apt  to  have  soft  areas.  The  presence  of 
other  foci  of  tuberculous  or  actinomycotic  disease  are  valua- 
ble aids  in  making  a  diagnosis,  but  the  occasional  simulta- 
neous occurrence  of  tuberculous  and  malignant  disease  is  not 
to  be  forgotten. 

The  evidences  of  chronic  intestinal  stenosis  and  a  palpable 
tumor  which  go  with  chronic  intussusception  may  lead  to 
the  diagnosis  of  malignant  disease;  but  the  absence  of 
emaciation  and  cachexia,  and  the  smooth,  doughy,  non- 
adherent characteristics  of  the  tumor  should  in  most  instances 
enable  us  to  differentiate  the  two. 

A  chronic  appendicitis  with  adhesions  and  exudate  is  dis- 
tinguished from  malignant  disease  by  the  clinical  history  of 
the  case,  by  the  absence  of  cachexia,  and  by  the  usual 
absence  of  intestinal  stenosis;  the  tumor  which  is  due  to 


298     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

appendicular  affections  is  not  so  hard  or  nodular  as  that 
due  to  a  malignant  neoplasm. 

Fecal  masses  in  the  bowel  are  distinguished  from  malignant 
tumors  by  their  soft,  indentable  character  and  by  their  disap- 
pearance after  free  catharsis.  Our  suspicion  of  malignant 
disease  should  be  aroused  if  a  patient  has  repeated  attacks  of 
obstinate  constipation,  and  gradually  loses  flesh  and  strength. 


TUMORS  OF  THE  MESENTERY  AND  OMENTUM. 

Mesenteric  Tumors. — Tumors  of  the  mesentery  are  to  be 
recognized  only  when  they  attain  sufficient  size  to  be  palpated. 
If  the  tumor  is  located  near  the  intestinal  end  of  the  mesen- 
tery it  enjoys  considerable  mobility  unless  it  has  become 
adherent  to  the  neighboring  viscera.  Its  adhesion  to  the 
abdominal  wall  is  infrequent. 

The  nature  of  the  tumor  is  difficult  to  determine. 

Fluid  Tumors. — The  fluid  tumors,  which  comprise  the 
serous,  hemorrhagic,  chylous,  echinococcic,  dermoid,  tera- 
toid, and  fetal  inclusion  cysts,  are  more  or  less  fluctuating 
and  of  slow  growth.  They  are  usually  unilocular  and  single; 
the  lymphatic  (chylous  cysts)  may  be  multiple. 

Mesenteric  tumors  of  this  class  are  distinguished  from 
omental  cysts  by  the  fact  that  the  latter  lie  nearer  to  the 
abdominal  wall  and  very  early  become  adherent  to  it.  From 
pancreatic  cysts  they  are  to  be  differentiated  by  the  history  of 
digestive  disturbances  or  cholelithiasis,  which  usually  precede 
the  former,  and  by  the  fact  that  the  outlines  of  pancreatic 
tumors  are  obliterated  when  the  stomach  and  colon  are  dis- 
tended. The  presence  of  sugar  in  the  urine  and  of  free 
fat  in  the  stools  are  further  confirmatory  evidences  of  the 
pancreatic  origin  of  the  cyst. 

Mesenteric  cysts  are  to  be  distinguished  from  ovarian 
cysts  by  the  relations  which  the  latter  have  to  the  uterus  and 
broad  ligament  (p.  347).  The  extension  of  ovarian  cysts 
from  below  upward  and  the  palpation  of  their  pedicle  through 
the  vagina  or  rectum  are  further  proofs  of  their  ovarian  origin. 

Sacculated  intraperitoneal  exudates,  usually  of  tubercu- 
lous origin,  may  very  much  resemble  a  mesenteric  cyst;  but 


NEOPLASMS  OF   THE  INTESTINE  299 

these  become  flattened  out  by  the  pressure  of  the  abdominal 
wall  and  overlying  intestines  when  the  patient  assumes  the 
recumbent  position,  whereas  mesenteric  cystic  tumors  retain 
their  globular  form. 

Solid  Tumors, — ^The  solid  mesenteric  tumors  belong  histo- 
logically to  the  lipoma,  lymphadenoma,  tuberculoma,  sarcoma 
or  carcinoma. 

The  lipomata  resemble  the  cystic  tumors,  but  are  said  to 
grow  much  more  rapidly.  The  malignant  neoplasms  are 
usually  secondary  deposits  in  the  glands  of  the  mesentery  and 
cause  a  rapid  deterioration  of  the  general  physical  condition. 

Omental  Tumors. — Omental  tumors  form  rounded  or 
flattened  masses  which  always  lie  close  to  the  abdominal 
wall,  to  which,  as  a  rule,  they  are  closely  connected.  If  the 
tumor  develops  after  a  laparotomy  or  herniotomy  or  inflam- 
mation of  the  abdominal  viscera,  it  is  of  an  inflammatory 
character.  Such  inflammatory  tumors  of  the  omentum  are 
apt  to  occasion  considerable  vomiting  of  a  hemorrhagic 
material  and  obstinate  constipation;  should  pus  form  it 
would  be  indicated  by  a  rise  in  temperature  and  an  increase 
in  the  leukocytes  up  to  20,000  or  30,000. 

Cystic  omental  tumors  are  usually  due  to  the  echinococcus. 

Carcinoma  and  sarcoma  are  usually  secondary  tumors. 

Torsion  of  Omentum. — Torsion  of  a  part  or  the  whole 
of  the  omentum  results  in  the  formation  of  a  lumpy  tumor 
with  narrow  or  thick  pedicle.  It  occasions  considerable 
peritoneal  irritation  and  serohemorrhagic  exudate  in  the 
peritoneal  cavity.  It  simulates  twisted  ovarian  cyst  or 
acute  appendicitis.  The  diagnosis  is  usually  made  only 
after  abdominal  section. 


CHAPTER    XXVIII. 

DISEASES  OF  THE  LIVER. 

The  normal  position  of  the  liver  is  in  the  right  hypo- 
chondrium  and  epigastrium,  behind  the  lower  chest  wall. 
Its  upper  border  in  the  sternal  line  is  at  the  base  of  the  ensi- 
form  cartilage;  in  the  parasternal  line  at  the  lower  border 
of  the  fifth  rib;  in  the  mammary  line  2^  cm.  above  the  upper 
border  of  the  sixth  rib;  in  the  axillary  line  at  the  upper 
border  of  the  seventh  rib.  The  lower  border  in  the  axillary 
line  is  between  the  tenth  and  eleventh  ribs;  in  the  mammary 
line  at  the  costal  margin;  in  the  median  line  about  midway 
between  the  ensiform  cartilage  and  the  umbilicus,  and  then 
it  rises  in  a  curved  direction  upward,  reaching  the  diaphragm 
between  the  left  parasternal  and  mammary  lines.  In  those 
who  have  lax  ligaments  and  flaccid  abdominal  walls,  and  in 
those  who  lace  tightly,  the  organ  always  lies  somewhat  lower. 

Only  the  lower  border  of  the  organ  can  under  normal 
conditions  be  palpated.  It  should  feel  sharp  and  smooth 
and  soft;  an  increased  resistance  or  an  undue  roundness, 
or  unevenness  or  tenderness  thereof  point  to  diseased  con- 
ditions of  the  organ. 


ABNORMAL  LOBES. 

Abnormal  lobes,  the  most  common  of  which  is  a  tongue- 
shaped  prolongation  of  the  right  lobe,  are  not  infrequently 
encountered,  and  are  especially  common  in  women  with  lax 
abdominal  walls.  They  result,  as  a  rule,  from  tight  lacing 
or  constriction  of  the  lower  costal  margin  during  adoles- 
cence, when  the  thorax  is  soft  and  flexible.  The  lobe  itself 
represents  a  movable  prolongation  of  the  liver  and  is  con- 
nected therewith  by  a  broad  or  narrow  pedicle.     The  pres- 


DISEASES  OF    THE  LIVER  301 

eiice  of  such  an  abnormal  lobe  is  made  manifest  by  pain  or 
by  attacks  of  twisting  or  inflammation  of  its  pedicle  on  ac- 
count of  which  the  lobe  becomes  painful,  tender,  and  of 
increased  size.  The  symptoms  occasioned  by  bihary  calculi, 
to  the  formation  of  which  the  abnormal  lobe  has  predisposed 
by  compression  or  kinking  of  the  cystic  duct,  or  the  presence 
of  a  tumor  in  the  right  side  of  the  abdomen,  are  additional 
evidences  of  such  abnormal  hepatic  lobes. 

Such  tumors  are  directly  connected  with  the  liver,  are 
demarcated  from  it  by  a  transverse  groove,  and  unless 
adhesions  have  formed  around  them  are  freely  movable. 
They  lie  above  the  transverse  colon.  Sometimes  they  appear 
to  occupy  the  loin  and  so  may  be  mistaken  for  displaced 
kidneys  and  tumors  of  the  kidney  and  adrenals.  They  can- 
not, however,  be  fully  replaced  into  the  loin  as  kidney  tumors 
can  be,  and  when  pressure  upon  them  is  relaxed  they  imme- 
diately assume  their  former  position.  Kidney  tumors  further- 
more lie  behind  the  colon,  or,  when  very  large,  protrude  for- 
ward with  the  colon  along  their  inner  side,  and  if  the  kidney 
is  diseased  the  cystoscopic  examination  of  the  bladder 
usually  reveals  changes  in  the  ureteric  mouths,  and  the 
ureteric  catheter  withdraws  abnormal  urine  from  the  corre- 
sponding side. 

A  distended  gall-bladder  is  to  be  distinguished  from  an 
abnormal  lobe  by  its  greater  lateral  mobility  and  by  the 
absence  of  a  groove  between  it  and  the  liver.  It  is  well  to 
remember,  however,  that  the  two  conditions  are  very  fre- 
quently associated,  the  lobe  lying  external  to  the  gall-bladder 
or  spread  out  over  its  surface;  they  may  both  have  long 
pedicles  and  reach  down  to  the  umbilicus. 

Tumors  around  the  appendix  can  be  differentiated  from 
abnormal  hepatic  lobes  by  their  clinical  history,  their  relation 
to  the  distended  colon,  and  the  absence  of  the  groove  that 
always  separates  an  abnormal  lobe  from  the  liver.  Appen- 
dicular tumors  are  rarely  as  smooth  or  tongue-shaped,  and 
are  apt  to  be  more  tender  and  less  movable. 

Tumors  of  the  hepatic  flexure  of  the  colon  are  distinguished 
from  abnormal  hepatic  lobes  by  the  chronic  intestinal  sten- 
osis which  attend  them. 

The  characteristic  flexion  of  the  thigh  and  deformity  of 


302      INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

the  spine  that  attend  psoas  abscess  readily  differentiate  this 
condition  from  the  one  under  discussion. 


FLOATING  LIVER. 

Floating  liver  is  a  rare  occurrence.  It  is  found  in  women 
with  very  lax  abdominal  walls,  and  is  indicated  by  a  tym- 
panitic resonance  where  the  liver  dulness  should  be.  When 
the  patient  assumes  the  recumbent  position  the  normal  area 
of  liver  dulness  returns.  Such  patients  suffer  from  pain, 
dragging  sensations,  gastric  disturbances,  portal  congestion, 
and  hemorrhoids. 

CONGENITAL  MALPOSITION  OF  LIVER. 

Congenital  malposition  of  the  liver  in  a  hernia  into  the 
umbilical  cord  has  already  been  referred  to  (p.  240).  Such 
children  usually  succumb  a  few  days  after  birth. 

LIVER  ABSCESS. 

It  is  essential  first  of  all  to  disabuse  our  minds  of  the 
impression  that  hepatic  suppurations  are  infrequent  in 
these  temperate  zones;  for  while  the  tropical  abscesses  of 
the  liver  which  are  secondary  to  simple  or  amoebic  dysentery 
are  relatively  infrequent  in  our  climates,  those  which  are 
secondary  to  purulent  affections  of  the  gall-bladder  and  bile- 
ducts — to  suppurative  and  ulcerative  diseases  within  the 
area  drained  by  the  branches  of  the  portal  vein  and  to  severe 
traumatisms  of  the  liver — are  quite  frequently  encountered. 

Tropical  Abscess, — The  clinical  story  of  a  patient  who 
has  a  tropical  abscess  of  the  liver  is  about  as  follows:  He 
has  or  had  a  diarrhoea;^  becomes  gradually  more  and  more 
sallow,  almost  cachectic  in  appearance,  emaciated,  is  subject 
to  psychical  depression,  gastric  disturbances,  and  profuse 
sweating,  and  runs  a  continuously  or  remittently  high  tem- 

1  It  is  strange  that  even  a  severe  diarrhoea  often  ceases  with  the  advent  of  the  liver 
suppuration. 


DISEASES   OF    THE    LIVER  303 

perature.  It  is  a  mistake  to  think  that  all  patients  with 
liver  abscess  are  jaundiced;  they  become  so  only  when  there 
is  an  associated  cholangitis,  or  when  the  abscess  presses  upon 
and  occludes  the  hepatic  or  common  bile-ducts.  Nor  is 
the  high  temperature  an  invariable  accompaniment  of  this 
variety  of  liver  suppuration,  for  in  those  cases  in  which  the 
abscess  is  surrounded  by  a  dense  fibrous  wall  the  temperature 
may  be  normal  or  but  slightly  elevated. 

Such  a  clinical  picture  should  always  arouse  our  suspicion 
of  a  liver  abscess,  and  should  prompt  us  to  carefully  examine 
this  organ.  A  small,  deeply  seated  abscess  may  afford  no 
local  evidences  of  its  presence;  if,  however,  we  are  reasonably 
sure  of  the  diagnosis  we  may  explore  the  liver  for  pus  with 
an  aspirating  needle.  It  is  to  be  remembered,  however,  that 
while  a  positive  result  of  such  aspiration  is  conclusive  evi- 
dence of  the  presence  of  an  abscess,  a  negative  result  is  not 
similarly  conclusive  a^gainst  it,  for  the  focus  may  be  so  small 
and  so  deep  as  to  escape  our  aspirating  needle. 

Larger  and  more  superficially  seated  abscesses  provoke 
pain,  which  may  radiate  to  the  shoulder  and  groin,  and 
which  is  increased  by  deep  respiration  and  compression  of 
the  thorax.  Tenderness  over  the  liver  is  likewise  present,  and 
is  most  acute  directly  over  the  seat  of  the  abscess.  Enlarge- 
ment of  the  liver  goes  with  all  abscesses  of  any  size,  and  the 
direction  of  the  enlargement  is  a  clue  to  their  seat.  Thus, 
if  the  abscess  is  in  the  upper  posterior  portion  of  the  liver 
the  enlargement  of  the  organ  is  upward  and  backward,  the 
right  lower  lobe  of  the  lung  being  compressed  and  the  lower 
limits  of  pulmonary  dulness  being  convex  upward;  if  it  is 
in  the  lateral  portion  of  the  convexity,  the  lower  ribs  and 
intercostal  spaces  are  bulged  outward;  and  if  it  is  in  the 
anterior  portion  of  the  organ,  either  near  the  convexity  or 
lower  surface,  the  abdominal  wall  below  the  costal  margin 
is  bulged  forward,  and  the  anterior  border  of  the  liver  is 
thickened  and  rounded.  If  the  abscess  is  in  the  left  lobe 
the  area  of  liver  dulness  to  the  left  is  increased. 

With  superficial  abscesses  the  cutaneous  veins  are  en- 
gorged, and  the  soft  parts  are  oedematous  and  fluctuating. 

Multiple  Abscesses. — With  multiple  abscesses  of  the  liver 
there  is  an  entirely  different  preceding  history  and  clinical 


304     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

course.  Thus,  as  a  rule,  some  intraperitoneal  suppuration 
or  an  ulceration  of  one  of  the  intra-abdominal  viscera,  or 
gallstone  disease,  cholangitis,  appendicitis,  etc.,  precedes  the 
development  of  the  liver  suppuration.  The  course  of  the 
malady  is  marked  by  repeated  chills  with  intermittently  high 
temperatures,  profuse  sweats,  rapid  emaciation,  and  increas- 
ing jaundice.  In  some  instances  the  course  is  less  acute;  the 
chills  are  infrequent,  sometimes  altogether  wanting;  the  tem- 
peratures are  very  irregular,  sometimes  quite  high  and  again 
near  to  the  normal;  and  gradually  increasing  pallor,  slight 
or  marked  jaundice,  emaciation,  and  weakness  develop. 

The  physical  signs  in  the  liver  are  the  same  as  with  the 
single  abscesses,  and  the  spleen  is  especially  likely  to  be 
enlarged. 

Though  the  diagnosis  of  liver  abscess  can,  as  a  rule,  be 
made  from  the  above-described  clinical  manifestations,  it 
should  always  be  confirmed  by  exploratory  puncture.  This 
should  be  made  with  a  fine-calibred  needle,  which  is  intro- 
duced at  the  point  of  greatest  tenderness.  Aspiration  is 
perfectly  safe  if  it  is  made  through  the  back  or  side  of  the 
chest,  but  if  the  abscess  is  located  in  the  epigastrium  or  in 
the  left  lobe  of  the  liver,  exploratory  incision  is  to  be  pre- 
ferred to  aspiration.  The  pus  which  is  most  frequently 
obtained  from  liver  abscesses  is  thick,  of  a  dirty  brown 
color  (like  soft  chocolate  ice  cream),  and  contains  liver  cells, 
pus  cells,  and  in  most  instances  some  variety  of  bacteria 
or  the  amoeba  coli  or  actinomyces.  A  culture  should  always 
be  made  from  it  at  once,  and  cover-glass  spreads  therefrom 
should  be  examined  under  the  microscope. 

The  leukocyte  count  is  not  of  much  aid  in  the  diagnosis 
of  liver  suppuration.  With  the  acute  varieties  it  is  usually 
somewhat  increased,  but  with  the  chronic  types  it  is  not 
materially  altered. 

The  possibility  that  a  hydrothorax,  pyothorax,  or  ascites 
may  complicate  the  liver  abscess  should  be  kept  in  mind; 
so  that  the  physical  signs  which  result  from  these  conditions 
should  be  properly  interpreted.  Perforation  of  the  abscess 
into  the  pleural  cavity  is  indicated  by  shock  and  intense 
dyspnoea,  and  is  followed  by  a  pyothorax.  Perforation  into 
the  peritoneal  cavity  has  already  been  considered  (p.  274). 


DISEASES  OF   THE   LIVER  305 

If  the  abscess  ruptures  into  the  intestine  or  through  the  dia- 
phragm into  the  kuig  and  then  into  a  bronchus,  there  will  be 
an  evacuation  of  the  pus  by  the  rectum  in  the  first  instance 
and  by  the  mouth  in. the  latter. 

A  liver  abscess  is  to  be  distinguished  from  an  uninfected 
echinococcus  cyst  of  the  liver  by  the  history  of  one  of  the 
usual  etiological  factors  for  this  condition,  by  the  presence 
of  fever,  a  painful  and  tender  liver,  and  by  the  emaciation 
and  sallowness  of  the  patient.  In  hydatid  disease  the  liver 
is  usually  rounded,  smooth,  and  tense,  and  in  some  instances 
hydatid  fremitus  may  be  obtained.  Infected  hydatid  cysts 
differ  from  abscesses  of  the  liver  in  that  the  acute  stage  of 
infection  is  preceded  by  a  long  period  of  digestive  disturb- 
ances with  enlarged  liver. 

The  swelling  in  the  right  hypochondrium  occasioned  by  a 
hydrops  or  empyema  of  the  gall-bladder  might  possibly  be 
mistaken  for  a  liver  abscess.  With  hydrops,  however,  there 
are  no  constitutional  disturbances  and  the  gall-bladder  is 
tense,  only  slightly  tender,  smooth,  and  movable;  with 
empyema  the  gall-bladder  is  tender,  usually  enlarged,  and 
somewhat  movable.  The  liver  is  not  enlarged  or  painful  or 
tender  in  either  case.  If  a  suppurative  cholangitis  develops 
secondary  to  these  inflammations  of  the  gall-bladder  the 
symptoms  of  hepatic  abscesses  would  also  become  manifested. 

A  kidney  shape,  a  hilus,  and  a  rounded  lower  border  dis- 
tinguish a  tumor  due  to  an  inflamed  right  kidney,  hydro- 
nephrosis, or  pyonephrosis  from  that  which  is  occasioned 
by  a  liver  abscess.  Furthermore,  a  kidney  can  be  replaced 
into  the  loin;  it  has  no  respiratory  mobility;  it  lies  behind 
the  distended  colon,  and  if  it  is  very  much  enlarged  it  ap- 
proaches the  anterior  abdominal  wall  to  the  inner  side  of 
the  distended  colon.  With  disease  of  the  kidney  the  urine 
often  contains  pus  or  blood.  With  periodical  hydronephro- 
sis the  tumor  appears  and  disappears;  with  its  appearance 
there  is  pain  in  the  loin,  vesical  tenesmus,  and  diminution 
in  the  amount  of  urine  passed  per  urethram;  with  its  dis- 
appearance the  pain  is  relieved  and  there  is  an  increased 
amount  of  urine  voided.  With  disease  of  the  kidney  the 
cystoscope  will  reveal  changes  in  the  mouth  of  the  right 
ureter,  and  catheterization  of  the  right  ureter  will  withdraw 

20 


306     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

altered  urine.  There  may  be  a  preceding  history  of  tuber- 
culosis or  renal  calculi  or  neoplasm.  With  hydronephrosis 
there  are  no  constitutional  symptoms. 

A  history  pointing  to  preceding  kidney  suppuration  would 
help  to  distinguish  a  paranephritic  abscess  from  liver  abscess, 
for  most  all  of  the  former  follow  upon  abscesses  of  the  kidney. 
In  those  instances  in  which  the  paranephritic  suppuration 
is  metastatic  to  suppuration  in  other  parts  of  the  body, 
and  especially  if  in  these  cases  the  pus  burrows  upward  be- 
hind the  liver,  the  differentiation  from  liver  abscess  may  be 
very  difficult. 

The  relation  which  a  pancreatic  swelling  bears  to  the 
stomach  and  colon  will  usually  suffice  to  distinguish  it  from 
that  which  is  due  to  a  liver  abscess.  A  preceding  history  of 
gallstone  disease,  the  presence  of  sugar  in  the  urine,  and  fat 
in  the  stools  are  additional  evidences  in  favor  of  pancreatic 
disease.  Furthermore,  cysts  and  tumors  of  the  pancreas  are 
not  attended  with  any  febrile  constitutional  disturbances, 
and  in  the  acute  forms  of  pancreatitis  these  evidences  are 
much  more  intense  than  they  are  with  liver  abscess. 

The  lack  of  the  characteristic  splenic  shape  and  notched 
anterior  border  help  to  differentiate  swellings  due  to  ab- 
scesses of  the  left  lobe  of  the  liver  from  swellings  of  the  spleen. 
The  absence  of  marked  gastric  symptoms  and  disturbance 
of  gastric  motility,  and  of  chemical  changes  in  the  gastric 
juice  help  to  distinguish  gastric  tumors  from  those  due  to 
chronic  liver  suppuration. 

The  chills  and  fever  attending  mutliple  liver  abscesses 
may  suggest  malaria,  but  there  is  here  no  regular  cycle  to 
the  paroxysms,  and  no  plasmodia  are  to  be  found  in  the 
blood.  Furthermore,  there  is  in  the  history  of  the  patient's 
illness  a  distinct  cause — e.  g.,  dysentery  or  intraperitoneal 
suppuration  or  ulceration  for  liver  abscesses. 


NEOPLASMS  OF  THE  LIVER. 

Hydatid  (Echinococcus)  Cysts. — These  constitute  the 
large  majority  of  the  fluid  tumors.  These  cysts  are  usually 
unilocular  and  single,  but  they  may  be  multilocular  and 


DISEASES  OF    THE  LIVER 


307 


multiple;  they  occur  most  frequently  in  women,  and  rarely  in 
children;  and  their  favorite  site  is  in  the  right  lobe.  When 
small  and  located  in  the  centre  of  the  liver  they  give  no  in- 
dication of  their  presence;  larger  cysts  form  elastic,  non- 
tender,    fluctuating   tumors   that   share   with   the   liver   its 


Hydatid  cyst  of  the  liver.    (Francis  H.  Markoe.) 

respiratory  mobility,  are  dull  to  percussion,  and  occasionally 
afford  an  hydatid  fremitus.^  They  may  occasion  pain  which 
radiates  to  the  right  shoulder,  shoulder-blade,  and  loin, 
some  fever  from  resorption  of  the  cystic  contents,  emacia- 
tion, and  weakness.  Icterus  is  present  only  when  the  chole- 
dochus  is  compressed  by  the  tumor  or  when  there  is  an 

1  Hydatid  fremitus  is  a  peculiar  vibratory  sensation  that  is  experienced  when  the 
cyst  is  palpated. 


308     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

associated  cholangitis.  The  cyst  usually  projects  from 
the  convexity  of  the  right  lobe  as  a  semiglobular  tumor, 
which  causes  the  lower  thoracic  wall  to  bulge  outward;  it 
may  project  from  the  under  surface  of  the  liver  in  the  form 
of  a  pedunculated  tumor,  and  if  the  pedicle  is  long  enough 
the  cyst  may  reach  down  into  the  lower  part  of  the  abdomi- 
nal cavity;  or  it  may  project  from  the  upper  surface  of  the 
liver  toward  the  thoracic  cavity  with  compression  of  the 
lung  and  heart.  If  it  is  located  in  the  left  lobe  it  may  extend 
over  so  far  to  the  left  that  the  dulness  it  occasions  merges 
with  splenic  dulness.  Large  cysts  compress  the  neighbor- 
ing organs — the  lungs,  heart,  kidneys,  stomach,  intestines, 
and  gall-ducts. 

Cyst  Contents. — The  cyst  contents  are  neutral  in  reaction, 
1000  or  1015  specific  gravity,  colorless,  contain  no  albumin, 
but  do  have  a  trace  of  sugar. 

Infection  of  Cyst. — The  development  of  fever,  of  continuous, 
remittent  or  intermittent  type,  with  or  without  chills,  rapid 
emaciation,  sweating,  and  rapid  increase  in  the  size  of  and 
tenderness  over  the  tumor  indicate  an  infection  of  the  cyst. 

Rupture  of  Cyst. — Rupture  of  the  cyst  into  a  neighboring 
hollow  viscus  is  recognized  by  the  escape  of  daughter  cysts 
in  the  stools  or  in  the  urine,  or  in  vomited  or  expectorated 
material.  Rupture  into  the  peritoneal  or  pleural  cavity  is 
followed  by  a  varying  degree  of  shock,  rise  of  temperature, 
and  an  urticarial  eruption  over  the  body.  The  extravasated 
cyst  contents  excite  a  peritonitis  or  pleuritis,  and  if  recovery 
takes  place  a  new  growth  of  cysts  will  take  place  in  these 
cavities  within  one  or  more  years.  Rupture  into  the  peri- 
cardium is  usually  fatal.  Rupture  into  the  bile-ducts  is 
followed  by  cholangitis  and  increasing  icterus,  and  as  the 
daughter  cysts  pass  through  the  ducts  they  occasion  attacks 
of  biliary  colic. 

In  another  chapter  we  have  mentioned  that  the  changes 
in  the  size  and  shape  of  the  liver  due  to  abscess  are  very 
similar  to  those  which  result  from  echinococcus  disease. 
Of  course  the  severe  grade  of  constitutional  symptoms 
readily  distinguishes  the  acute  liver  abscesses  from  hydatid 
cysts,  but  the  chronic  variety  of  abscesses  bear  them  some 
resemblance.      It   is   to   be   noted,   however,   that   patients 


DISEASES  OF    THE   LIVER  309 

suffering  with  this  variety  of  abscess  usually  give  a  preced- 
ing history  of  diarrhoea,  or  of  trauma  over  the  liver,  or  of 
cholelithiasis;  they  are  much  more  sallow  and  emaciated, 
and  the  liver  or  tumor  is  more  tender  and  less  tense.  If 
the  cyst  has  ruptured  and  daughter  cysts  have  escaped  in 
the  stools  or  in  the  urine  or  have  been  expectorated  or 
vomited,  the  differential  diagnosis  is  very  easily  made. 

A  preceding  history  of  ulceration  or  suppuration  of  an 
intraperitoneal  organ  and  an  acute  onset  and  course  dis- 
tinguish the  acute  liver  abscesses  from  the  infected  hydatid 
cyst;  furthermore  the  echinococcus  cysts,  as  a  rule,  exist  for 
a  long  time  prior  to  their  infection,  and  during  this  uninfected 
period  the  patient  suffers  from  chronic  gastrointestinal  dis- 
turbance with  some  emaciation. 

The  multiplicity  of  the  nodules,  their  hardness,  tender- 
ness, and  rapid  growth  distinguish  carcinoma  of  the  liver 
from  hydatid  disease.  The  presence  of  a  primary  growth  in 
some  one  of  the  other  abdominal  viscera,  to  which  the  liver 
manifestation  is  secondary,  and  the  cachectic  and  some- 
what icteric  appearance  of  the  patient  help  us  materially 
in  making  the  differentiation  between  the  two  conditions. 

Wasting  diseases  and  prolonged  suppuration  are  attended 
with  an  enlargement  of  the  liver  due  to  its  amyloid  or  fatty 
degeneration.  But  in  these  cases  the  organ  is  uniformly 
and  generally  enlarged  and  smooth  and  not  painful,  and  the 
preceding  history  of  a  wasting  malady  furnishes  an  explana- 
tion for  the  liver  and  splenic  changes. 

Non-parasitic  liver  cysts  can  only  be  differentiated  from 
the  hydatid  variety  by  examination  of  the  cyst  wall  and 
the  cyst  contents.  The  cyst  contents  are  to  be  obtained  by 
exploratory  puncture;  this  is  never  to  be  practised,  how- 
ever, unless  all  preparations  for  immediate  operation  have 
been  previously  made,  for  extravasation  of  the  cyst  con- 
tents into  the  peritoneal  cavity  along  the  track  of  the  needle 
may  follow  such  puncture  and  fever,  urticaria,  and  peritonitis 
result  therefrom. 

A  pedunculated  hydatid  cyst  projecting  from  the  under 
surface  of  the  liver  may  be  mistaken  for  a  distended  gall- 
bladder. But  with  this  latter  condition  there  is  a  preceding 
history  of  biliary  colic,  possibly  of  jaundice,  and  the  passage 


310     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

of  stones  in  the  stools.  The  tumor  formed  by  a  distended 
gall-bladder  is  oval-shaped,  smooth,  and  is  more  frequently 
movable  than  a  hydatid  cyst. 

Hydronephrotic  and  pyonephrotic  tumors  bear  a  super- 
ficial physical  resemblance  to  pedunculated  hydatid  cysts, 
but  they  can  be  readily  differentiated  from  them,  for  they 
lie  behind  the  colon,  have  no  respiratory  mobility,  and  can 
be  replaced  into  the  loin,  which  position  they  maintain  as 
long  as  the  patient  occupies  the  recumbent  position.  Fur- 
thermore, with  these  kidney  lesions  there  are  usually  changes 
in  the  urine.  With  periodical  hydronephrosis  there  are 
variations  in  the  size  of  the  growth;  and  as  the  kidney  tumor 
diminishes  in  size  there  is  an  increase  in  the  amount  of  urine 
which  is  voided.  The  altered  appearances  of  the  ureteral 
mouths  in  diseased  conditions  of  the  kidney,  together  with 
the  abnormal  constituents  in  the  urine  drawn  from  such 
kidneys  by  the  ureteral  catheter,  are  additional  data  for 
the  recognition  of  kidney  abnormalities   and  disease. 

The  position  of  pancreatic  cysts  behind  the  stomach  and 
colon,  or  below  the  latter  or  above  the  former,  and  their 
lack  of  respiratory  mobility,  distinguishes  them  from  hydatid 
disease  of  the  liver.  A  preceding  history  of  gallstone  dis- 
ease and  the  presence  of  sugar  in  the  urine  and  fat  in  the 
stools  are  additional  diagnostic  evidences  in  favor  of  the 
pancreatic  origin  of  the  cyst. 

Mesenteric  cysts.  (See  p.  336.)  Splenic  tumors  differ  from 
cysts  of  the  left  lobe  of  the  liver  by  their  characteristic  shape 
and  their  notched  border. 

Subphrenic  echinococcus  liver  cysts  are  to  be  differen- 
tiated from  pleural  effusions  and  subphrenic  abscesses. 

Pleurisy  with  effusion  has  an  acute  onset  with  an  acute 
course.  It  commences  with  a  chill,  high  fever,  pain  in  the 
side,  and  dyspnoea;  as  the  effusion  accumulates  the  dyspnoea 
becomes  worse,  the  thorax  (ribs  and  intercostal  spaces)  dis- 
tended and  barrel-shaped,  the  heart  and  mediastinum  dis- 
placed, and  the  entire  liver  depressed;  if  the  effusion  is  free 
it  changes  its  level  with  changes  of  the  patient's  position. 
With  pleurisy  the  area  of  compressed  breathing  extends  up 
to  the  upper  lobe,  while  with  a  subphrenic  hydatid  cyst  ves- 
icular breathing  extends  down  to  the  level  of  the  cyst.     In 


DISEASES  OF    THE  LIVER  311 

the  latter  affection  the  onset  and  progress  of  growth  are 
slow,  and  the  dyspnoea  becomes  very  gradually  worse;  as 
the  cyst  increases  in  size  it  distends  the  thorax  in  a  single 
area  and  the  thorax  has  a  bell-shape.  The  liver  is  depressed 
by  it  only  in  part — e.  g.,  in  front  or  in  back.  Pain  radiating 
to  the  back  or  shoulder  is  present,  and  if  the  liver  can  be 
palpated  the  circumscribed  bulging  of  the  cyst  can  be  de- 
tected. With  empyema  or  chronic  serous  pleurisy  there  is 
deterioration  of  the  general  health.  Exploratory  puncture 
determines  the  presence  of  serous  or  purulent  exudates. 

Subphrenic  abscess  is  secondary  to  a  ruptured  hollow  viscus, 
or  to  suppuration  within  the  abdomen,  and  the  signs  of  these 
primary  maladies  are,  as  a  rule,  quite  clear.  There  is  no 
previous  history  of  liver  pain  or  of  an  enlarged  liver  or  of 
the  passage  of  daughter  cysts. 

Pyopneumothorax  has  an  acute  onset,  with  cough,  dyspnoea, 
expectoration,  and  some  collapse.  The  heart  and  mediastinal 
structures  are  displaced.  The  entire  lung  is  compressed;  the 
breathing  is  labored  and  dyspnoeic;  there  is  a  succussion 
splashing  sound  on  shaking  the  patient. 

Subphrenic  cysts  are  distinguished  from  supraphrenic  cysts 
by  the  following  signs :  In  subphrenic  cyst  the  thorax  bulges 
in  one  place  like  a  bell;  in  supraphrenic  cyst  it  is  uniformly 
bulging  like  a  barrel.  Subphrenic  cysts  push  up  the  dia- 
phragm, and  soon  paralyze  it;  they  consequently  cease  to 
move  with  respiration.  Supraphrenic  cysts  push  down  the 
diaphragm  and  the  entire  liver,  but  as  they  do  not  paralyze 
the  former,  they  retain  respiratory  mobility.  The  supra- 
phrenic cysts  very  early  give  evidences  of  pleural  involvement. 

Nonparasitic  Cysts. — Nonparasitic  cysts  of  the  liver  are 
either  biliary  duct  reteiition  cysts,  or  dermoids  or  lymph  cysts, 
or  cystic  adenoma.  They  form  solitary  cysts,  and  are  located 
near  the  liver  surface.  The  symptoms  are  similar  to  those 
given  by  the  hydatid  cysts. 

Cystic  Degeneration  of  Liver. — Cystic  degeneration  of 
liver  occurs  frequently  in  conjunction  with  cystic  degen- 
eration of  the  kidneys.  The  liver  feels  lumpy.  The  diagnosis 
is  to  be  made  only  by  exploratory  incision. 

Solid  Tumors. — Of  the  soUd  tumors  of  the  liver  the 
syphilomata,  the  fibromata,  the  angiomata  and  the  adenomata 


312     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

are  the  most  frequently  encountered  benign  growths,  while 
the  carcinomata  and  sarcomata  are  the  usual  varieties  of  the 
malignant  neoplasms. 

The  syphilitic  lesions  of  the  liver  that  concern  us  most 
from  a  diagnostic  standpoint  are  the  nodular  and  lobulated 
conditions  of  the  organ.  The  nodules  vary  in  size  from  a 
split  pea  to  a  hen's  egg,  and  are  most  frequently  located 
along  the  suspensory  ligament,  in  Glisson's  capsule,  at  the 
portal  fissure  and  along  the  main  branches  of  the  portal  vein. 
The  diagnosis  of  this  condition  depends  upon  an  antecedent 

Fig. 130 


Syphilitic  eulargement  of  the  liver  and  spleen ;  multiple  gummata  of  the  liver; 
laparotomy  and  removal  of  one  tumor  for  examination;  cure  by  subsequent  treat- 
ment (drawn  from  life).    (Von  Bergmann.) 


liistory  of  syphilis  and  upon  the  improvement  that  follows 
from  the  administration  of  iodide  of  potassium.  Sometimes 
these  nodules  become  quite  painful  and  sensitive,  the  pain 
being  very  similar  to  that  of  gallstone  disease,  and  should 
there  be  a  nodule  at  the  gall-bladder  site,  it  may  be  mistaken 
for  a  hard,  contracted  gall-bladder  containing  calculi.  In 
such  cases  a  previous  history  of  syphilis,  the  presence  of 
syphilitic  lesions  in  the  other  organs  (bones,  skin,  mucous 
membranes),  the  presence  of  other  nodular  masses  in  the 
liver,  and  the  improvement  which  is  obtained  from  anti- 
syphilitic  treatment  speak  strongly  in  favor  of  the  swelling 


DISEASES   OF    THE  LIVER  3l3 

being  a  syphiloma.  Should  these  nodules  undergo  softening 
or  suppuration,  the  symptoms  to  which  they  would  then 
give  rise,  viz.,  irregular  fever,  disturbances  in  the  general 
health,  and  the  presence  of  a  painful,  tender  mass  in  the  liver, 
would  resemble  very  much  those  which  accompany  a  chronic 
liver  abscess;  the  differentiation  is  in  most  instances  impos- 
sible without  the  aid  of  a  definite  antecedent  history  of 
syphilis  or  of  an  etiological  cause  for  the  liver  abscess.  If 
these  cannot  be  elicited,  an  exploratory  incision  is  the  only 
way  in  which  we  can  make  a  diagnosis. 

An  isolated  lobule  that  is  sometimes  formed  in  a  syphilitic 
liver  as  the  result  of  the  contraction  of  newly  formed  con- 
nective-tissue bands  may  resemble  a  floating  kidney,  for  the 
differentiation  of  which  the  reader  is  referred  to  page  384. 

Fibromata  and  angiomata  give  rise  to  symptoms  only  when 
they  are  large  enough  to  cause  pressure  upon  the  neighboring 
structures.  Examination  then  shows  the  presence  of  a 
rounded,  firm,  non-tender  tumor. 

Adenomata  occur  in  the  form  of  multiple  nodes  or  as 
single  tumors,  which  are  well  encapsulated.  They  may 
occasion  toxic  marasmus  from  pressure  upon  the  bile-ducts. 
Attention  is  drawn  to  their  presence  when  they  produce 
pressure  upon  neighboring  structures  and  interfere  with 
general  well-being. 

Carcinomata  and  sarcomata  are  usually  metastatic  tumors. 
Their  presence  in  the  liver  adds  to  the  cachexia  resulting 
from  the  primary  growth  and  causes  icterus  (usually  from 
pressure  on  the  bile-ducts),  loss  of  flesh  and  strength,  dis- 
turbed digestion,  and  ascites.  The  liver  is  enlarged  and 
nodular,  or  it  presents  a  single  tumor  which  is  painful  and 
tender,  and  its  anterior  margin  is  much  thickened. 


CHAPTER   XXIX. 

DISEASES  OF  THE  GALL-BLADDER. 

The  gall-bladder  normally  occupies  a  position  on  the 
under  surface  of  the  right  lobe  of  the  liver,  its  fundus  touch- 
ing the   anterior   abdominal   wall    below   the   ninth   costal 


Fig.  131 


Palpating  gall-bladder  :  Examiner  stands  on  right  side  of  the  patient,,  facing  Ms 
feet,  and  palpates  the  under  surface  of  the  liver  and  gall-bladder  region. 

cartilage,  just  outside  of  the  external  edge  of  the  right  rectus 
muscle.  Changes  in  the  position  of  the  liver  or  adhesions 
between  the  gall-bladder  and  adjacent  viscera  alter  its  posi- 
tion. This  viscus  can  only  be  palpated  when  it  is  distended. 
To  palpate,  the  examiner  should  stand  on  the  right  side  of 
the  patient,  facing  his  legs,  and  press  his  fingers  underneath 
the  liver. 


DISEASES  OF   THE  GALL-BLADDER  315 


CHOLELITHIASIS. 

Mainly  through  the  efforts  of  Riedel,  Courvoisier,  and 
Kehr,  and,  for  the  most  part,  from  the  accurate  data  obtained 
by  them  from  exploratory  laparotomy,  has  the  diagnosis  of 
gallstone  disease  been  placed  upon  a  sound  basis.  We  are 
no  longer  satisfied  when  we  have  established  the  fact  that 
our  patient  suffers  with  cholelithiasis;  we  desire  also  to  know 
the  site  of  the  stones,  and  whether  any  complicating  diseases 
or  conditions  of  the  biliary  apparatus  are  present. 

While  biliary  calculi  do  occasionally  form  in  the  bile- 
ducts,  their  most  frequent  site  of  formation  is  in  the  gall- 
bladder, from  which  place  they,  as  a  rule,  sooner  or  later 
wander  into  the  ducts,  there  to  be  impacted  or,  as  more 
frequently  happens,  to  be  passed  on  into  the  intestine.  Their 
mere  presence  in  the  iminfected  gall-bladder  usually  gives  rise 
to  no  symptoms,  but  in  some  cases  they  occasion  more  or  less 
severe  pain,  which  is  located  in  the  epigastrium  and  radiates 
to  the  back  and  right  shoulder,  or  is  confined  only  to  the  back 
opposite  the  eleventh  and  twelfth  dorsal  vertebrae.  As  there 
are  no  physical  findings  to  explain  this  pain,  and  because  it  is 
frequently  aggravated  by  a  heavy  meal  and  is  attended  with 
gas  and  acid  eructations,  the  diagnosis  of  gastric  neuralgia, 
hyperacidity  of  the  gastric  juice,  etc.,  is  frequently  erroneously 
made.  But  these  are  not  diseases ;  they  are  merely  symptoms ; 
and  if  at  first  we  are  not  able  to  positively  decide  upon  their 
underlying  cause,  we  should  continue  to  carefully  observe 
the  patient  until  we  have  additional  data  upon  which  to 
base  a  diagnosis.  In  most  cases  of  gallstone  disease  such 
data  will  sooner  or  later  be  forthcoming,  either  from  the 
wanderings  of  the  calculi  into  the  ducts  or  from  the  addition 
of  a  secondary  infection  of  the  biliary  apparatus. 

Passage  of  Stones  into  Ducts. — The  passage  of  a  stone 
into  or  through  the  ducts  into  the  intestine  usually  excites  an 
attack  of  biliary  colic,  which  is  marked  by  severe  cutting, 
colicky  pain  referred  to  the  right  hypochondrium  and  radi- 
ating to  the  back  and  right  shoulder,  by  prostration,  and  by 
vomiting  of  gastric  contents  and  bile.  With  it  the  tempera- 
ture may  be   moderately  elevated,    and   the   liver   slightly 


316     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

enlarged;  directly  after  it  the  patient  becomes  icteric,  the 
stools  clayey  in  color,  and  if  they  are  carefully  washed  and 
sifted  the  calculi  may  be  found/ 

Impaction  of  Stones  in  Ducts.— If  the  stone  becomes 
impacted  in  the  cystic  duct  and  occludes  it,  or  if  the  latter 
becomes  obstructed  in  any  other  way — e.  g.,hj  a  kink  or  by 
contraction  of  surrounding  adhesions,  the  gall-bladder  usually, 
but  by  no  means  always,  becomes  distended;  its  distention 
is  impossible  if  from  previous  inflammation  and  ulceration  it 
has  become  shrunken  and  contracted  and  its  walls  thick  and 
inelastic.  A  distended  gall-bladder  lies  along  a  line  drawn 
from  the  tip  of  the  ninth  costal  cartilage  downward  parallel 
to  the  outer  border  of  the  rectus  muscle.  It  forms  a  smooth, 
rounded,  tender  tumor  that  has  respiratory  and  lateral 
mobility,  and  the  dulness  it  affords  on  percussion  is  usually 
continuous  with  that  of  the  liver.  Jaundice  is  not  present 
in  such  cases  unless  the  distended  gall-bladder  compresses 
the  common  bile  or  hepatic  ducts,  or  unless  there  is  an  infec- 
tion of  the  ducts  (cholangitis). 

A  distention  of  the  gall-bladder  without  icterus  points  to 
cystic  duct  obstruction,  the  obstructing  cause  being  usually 
a  calculus,  less  frequently  a  kink  or  cicatricial  stenosis.  A 
distention  of  the  gall-bladder  with  icterus  points  to  com- 
pression or  occlusion  of  the  common  bile-duct  by  a  tumor. 
The  reason  for  this  latter  will  be  seen  later. 

If  the  stone  becomes  impacted  in  the  hepatic  or  common 
bile-ducts  and  causes  their  sudden  and  complete  occlusion, 
there  will  be  a  gradually  increasing  icterus,  emaciation, 
acholic  stools,  slight  fever,  and  a  tendency  to  hemorrhages 
from  the  mucous  membranes.  The  gall-bladder  is  not  likely 
to  be  distended,  for,  as  a  rule,  the  impaction  of  stones  in  the 
ducts  goes  with  the  later  stages  of  gallstone  disease,  after 
there  have  been  repeated  attacks  of  cholecystitis,  as  a  result 
of  which  the  gall-bladder  has  become  contracted.  The  liver 
may  be  enlarged  and  cirrhotic,  but  it  is  not  tender. 

If  the  stones  in  these  ducts  only  partially  occlude  them  or 
act  as  ball  valves,  sometimes  occluding  and  sometimes  not 

1  It  is  important  to  note  that  the  calculi  may  not  be  passed  in  the  stools  for  several 
days  after  the  colic  has  subsided,  hence  the  importance  of  examining  the  stools  for  at 
least  a  week  after  an  attack. 


DISEASES  OF   THE  GALL-BLADDER  317 

occluding  the  channels,  there  may  be  no  jaundice,  or  peri- 
odical jaundice,  or  jaundice  of  varying  intensity,  and  the 
disturbances  in  the  general  health  are  only  very  slight. 
Jaundice  may  be  absent  with  stones  lodged  in  the  common 
bile-duct  under  the  following  conditions:  Either  they  are 
too  small  to  entirely  obstruct  the  channel,  or  the  cystic  duct 
is  patent  and  a  pathological  fistula  exists  between  the  gall- 
bladder and  intestine. 

Infection  of  the  Biliary  Apparatus. — The  presence  of 
stones  in  the  biliary  apparatus  renders  this  much  more  likely 
to  infection.  The  wanderings  of  the  stones  are  by  many 
attributed  to  such  a  mixed  or  secondary  infection;  but  how- 
ever this  may  be,  the  other  clinical  evidences  of  such  infec- 
tion are  very  pronounced. 

If  the  irifection  is  limited  to  the  gall-bladder,  and  the 
cystic  duct  is  coincidently  occluded  either  by  a  stone  that 
has  wandered  into  it  or  by  the  inflammatory  swelling  of  its 
mucous  membrane,  the  symptoms  will  vary  with  the  viru- 
lency  of  the  infecting  organism  and  with  the  severity  of  the 
inflammation. 

Acute  Cholecystitis. — A  mild  inflammation  is  attended  with 
moderate  fever,  somewhat  increased  pulse  rate,  pain,  and 
distention  of  the  gall-bladder.  With  the  severer  forms  of 
inflammation  the  fever  is  higher  (103°  to  104°),  the  pulse  rate 
more  rapid,  there  is  vomiting,  severe  pain,  and  considerable 
gall-bladder  distention.  In  the  severest  cases,  with  local  or 
general  gangrene  of  the  gall-bladder,  and  local  or  diffuse 
peritonitis,  the  patient  is  very  sick;  the  expression  is  drawn 
and  anxious,  the  tongue  is  dry,  the  pulse  rapid,  the  tempera- 
ture 104°  or  over,  and  the  abdomen  distended;  there  is  severe 
pain  over  the  gall-bladder,  with  considerable  distention  of 
the  viscus  and  local  or  general  abdominal  rigidity.  With 
perforation  or  complete  gangrene  of  the  gall-bladder  a  septic 
peritonitis  ensues.  With  the  mild  grade  of  infection  of  the 
gall-bladder  the  viscus  is  filled  with  mucus  and  bile  and  serum 
(acute  hydrops) ;  with  the  severer  grades  it  is  filled  with  bile 
and  pus  (acute  empyema). 

The  milder  grades,  and  even  some  of  the  severer  ones, 
subside  spontaneously  if  the  obstruction  to  the  cysticus  is 
relieved  by  the  passage  of  the  stone  into  the  intestine,  or  the 


318     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

falling  back  of  the  stone  into  the  gall-bladder.  Perichole- 
cystitic  adhesions  or  ulcerations  of  the  gall-bladder  remain 
after  the  severer  forms.  A  mixed  infection  of  the  gall-bladder 
having  once  taken  place,  recurrent  attacks  are  sure  to  occur, 
until  the  gallstones  are  removed  and  the  viscus  drained,  and 
thereby  its  infection  relieved.  The  ulceration  and  subsequent 
cicatrization  which  result  from  recurrent  attacks  of  acute 
cholecystitis  finally  bring  about  a  contraction  of  the  gall- 
bladder, and  a  thickening  and  inelasticity  of  its  walls. 

Chronic  Cholecystitis. — ^The  contraction  of  adhesions  may 
cause  a  kink  in  the  cysticus;  likewise  the  cicatrization  of 
ulcers  near  the  cystic  orifice  of  the  gall-bladder  may  result 
in  stenosis  or  permanent  closure  of  the  cystic  duct.  The 
mucus  and  serum  and  pus  which  is  secreted  by  the  infected 
mucous  membrane  cannot  then  escape,  and  chronic  hydrops 
or  chronic  empyema  of  the  gall-bladder  results.  With  these 
chronic  forms  of  cholecystitis  there  are  very  slight  consti- 
tutional symptoms.  The  distended  gall-bladder  occasions  a 
feeling  of  weight  and  pain. 

It  is  to  be  especially  noted  that  no  jaundice  accompanies 
acute  or  chronic  cholecystitis,  unless  the  distended  viscus 
compresses  the  common  bile  or  hepatic  ducts. 

Cholangitis. — If  the  infection  is  located  in  the  ducts,  a 
cholangitis  develops.^  This  may  occur  together  with  or  inde- 
pendently of  a  cholecystitis.  If  it  is  acute  and  septic  in 
character,  it  occasions  repeated  chills,  intermittent  or  remit- 
tent temperature  elevations,  sweating,  jaundice,  rapid  emacia- 
tion, and  a  tendency  to  bleeding  from  the  mucous  mem- 
branes. The  stools  are  not  completely  acholic.  The  liver 
becomies  much  enlarged,  tender,  and  painful,'and  may  contain 
small  abscesses. 

Ulceration  of  Stones  Through  Biliary  Channels. — One 
other  complication  may  result  from  biliary  calculi.  Wlien 
they  are  confined  in  the  gall-bladder  or  ducts,  they  may 
ulcerate  through  these  structures  into  a  neighboring  hollow 

1  It  is  to  be  especially  noted  that  the  infection  of  the  gall-bladder  and  bile-ducts 
may  remain  after  the  calculi  have  passed.  This  fact  will  explain  those  increasingly 
frequent  cases  in  which  a  diagnosis  of  gallstones  with  cholecystitis  or  cholangitis 
was  made,  and  yet  no  stones  were  found  on  opening  the  abdomen,  but  only  an  acute 
or  chronic  cholecystitis  or  cholangitis. 


DISEASES  OF   THE  GALL-BLADDER  319 

viscus — e.  g.,  the  stomach,  duodenum,  intestines  or  kidney, 
or  into  the  peritoneal  cavity.  There  may  be  no  evidences 
of  such  ulceration,  or  there  may  be  signs  of  a  local  adhesive 
peritonitis.  Once  the  stone  has  passed  into  a  neighboring 
viscus,  it  may  give  no  further  trouble,  or  if  it  is  very  large 
it  may  obstruct  the  channel  of  its  new  habitat.  (See  Intestinal 
Obstruction  from  Gallstones.) 

The  diagnosis  of  gallstone  disease  is  thus  seen  to  depend 
on  the  presence  of  pain  in  the  right  hypochondrium  or 
epigastrium  or  in  the  back  opposite  the  eleventh  and  twelfth 
dorsal  vertebrae,  on  the  occurrence  of  attacks  of  biliary  colic 
with  the  passage  of  stones  in  the  stools,  on  the  presence  of 
jaundice  and  of  fever.  No  aid  is  to  be  obtained  from  the 
rr-ray  examination,  for  biliary  calculi  rarely  cast  shadows. 

It  is  important  to  remember  that  jaundice  in  gallstone 
disease  occurs  only  from  obstruction  or  compression  or 
inflammation  of  the  primary  and  subsidiary  hepatic  ducts 
or  common  bile-duct,  and  that  when  the  calculi  are  confined 
to  the  gall-bladder  or  cystic  duct,  there  is  no  jaundice,  unless 
the  distended  gall-bladder  presses  upon  the  hepatic  or 
common  bile-ducts,  or  unless  there  is  a  cholangitis.  Further, 
it  is  important  to  note  that  the  gall-bladder  is  not  always 
distended  in  calculus  disease.  Distention  of  the  gall-bladder 
points  to  obstruction  of  the  cystic  duct;  a  gall-bladder  with 
elastic  walls  distends  so  as  to  accommodate  the  stagnant 
contents,  but  a  gall-bladder  whose  walls  are  infiltrated, 
thickened,  and  cicatricial  from  repeated  attacks  of  inflam- 
mation is  inelastic  and  cannot  distend. 

Determination  of  Site  of  Stones. — The  location  of  the 
stones  is  to  be  determined  from  the  condition  of  the  gall- 
bladder and  from  the  presence  or  absence  of  jaundice  and 
clayey  stools ;  the  existence  of  complicating  inflammation  of 
the  gall-bladder  and  ducts  is  to  be  determined  from  the  con- 
stitutional symptoms  and  from  the  presence  of  a  distended, 
painful,  exquisitely  tender  gall-bladder,  or  of  an  enlarged, 
painful  arid  tender  liver. 

If  the  stones  are  located  in  the  gall-bladder  and  the  cystic 
duct  is  open,  there  will  be  only  pain  and  attacks  of  colic; 
the  gall-bladder  is  not  distended.  If  the  cystic  duct  is 
obstructed  by  a  calculus  or  by  a  kink  or  by  cicatricial  stenosis, 


320     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

the  gall-bladder  is  distended.  There  is  no  jaundice  unless 
the  distended  viscus  presses  upon  the  hepatic  or  common 
bile-ducts,  or  unless  there  is  a  cholangitis  present. 

Firmly  impacted  stones  in  the  choledochus  or  hepaticus 
cause,  in  addition  to  the  pain  and  colic,  an  increasing  jaundice 
with  acholic  stools;  with  ball-valve  stones  there  may  be  no 
jaundice  or  intermittent  jaundice  or  jaundice  of  a  varying 
intensity;  tlie  color  of  the  stools  varies  according  to  the 
presence  and  degree  of  jaundice.  The  gall-bladder  is  not 
likely  to  be  distended  in  either  case,  because  preceding  attacks 
of  cholecystitis  have  rendered  its  walls  rigid,  inelastic  and 
contracted,  and  incapable  of  yielding  to  the  increasing  pres- 
sure of  the  dammed-up  bile. 

Those  cases  of  cholelithiasis  that  only  occasion  cholecystitic 
pain  must  be  differentiated  from  cases  of  lead  colic,  gastric 
ulcer,  kidney  colic,  and  intestinal  colic.  If  the  individual  is 
a  painter  or  worker  in  lead  and  has  a  blue  line  on  the  gums, 
and  confesses  to  neglect  in  the  care  of  his  hands  and  clothing 
before  eating,  we  are  safe  in  diagnosing  a  lead  colic.  If  the 
pain  is  aggravated  by  eating,  is  attended  with  a  gastric  ulcer 
"Head"  zone,  with  hyperacidity  and  possibly  with  hsema- 
temesis,  a  gastric  ulcer  is  probably  its  cause.  If  it  is  attended 
with  frequent  urination,  possibly  with  haematuria,  and  radiates 
downward  into  the  groin,  testicle,  and  thigh,  and  if  the  cysto- 
scope  reveals  changes  in  the  ureteral  orifice  (for  which  see 
p.  374),  a  kidney  stone  or  other  abnormal  kidney  condition 
is  probably  present.  In  intestinal  colic  the  pain  is  more 
general  over  the  abdomen,  and  is  relieved  by  a  cathartic  or 
high  enema. 

As  the  formation  of  biliary  calculi  is  favored  by  biliary 
stasis  and  excited  by  an  infection  of  the  biliary  passages  with 
bacteria  of  diminished  virulence,  the  presence  of  conditions 
favoring  biliary  stasis — e.  g.,  nephroptosis,  or  enteroptosis, 
and  the  history  of  a  preceding  systemic  infection — e.  g.,  by 
the  typhoid  bacillus  or  other  organisms  whose  elimination 
from  the  blood  is  accomplished  by  the  liver  and  carried  by 
the  bile  into  the  bile  passages,  are  points  in  favor  of  calculous 
disease  of  the  biliary  organs. 

Those  cases  that  exhibit  cholecystitic  pain  plus  chole- 
cystitis and  a  distended  gall-bladder  must  be  differentiated 


DISEASES  OF   THE  GALL-BLADDER 


321 


in  their  acute  stage  from  acute  appendicitis.  Gall-bladder 
disease  is  distinguished  by  the  history  of  previous  attacks 
of  colic  with  or  without  fever  or  jaundice,  and  by  the  pear- 
shaped  tumor,  with  its  respiratory  and  lateral  mobility  and 
its  close  relations  to  the  liver. 

A  preceding  history  of  pain  and  colic  distinguishes  a 
tumor  due  to  a  chronic  hydrops  or  empyema  of  the  gall- 
bladder.   The  tumor  itself  differs  from  kidney  tumors  in  that 

Fig. 132 


Reidel's  lobe  of  liver,  frequently  present  in  gallstone  disease,  and  often 
spread  out  over  an  enlarged  gall-bladder. 


it  has  not  the  characteristic  kidney  shape,  it  lies  above  the 
colon  and  not  behind  it,  and  it  cannot  be  fully  replaced  into 
the  loin.  By  distention  of  the  stomach  and  by  chemical 
examination  of  the  gastric  contents  tumors  of  the  stomach 
may  be  differentiated  from  enlargements  of  the  gall-bladder. 
Echinococcus  cysts  can  be  differentiated  from  enlarged 
gall-bladders  by  their  history  and  their  slow  growth,  and 
syphilomata  of  the  liver  by  an  antecedent  history  of  syphilis, 

21 


322     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

the  multiplicity  of  the  nodules,  the  thickening  of  Glisson's 
capsule  with  the  consequent  rounding  out  of  the  sharp 
anterior  border  of  the  liver,  and  by  the  improvement  from 
antispecific  treatment.  Riedel  lays  great  stress  on  the  pres- 
ence of  a  tongue-shaped  lobe  of  the  liver  at  the  site  of  the 
gall-bladder  as  pointing  to  a  hydrops  of  the  viscus. 

Cholelithiasis  with  obstructive  jaundice,  the  stones  being 
impacted  in  or  floating  up  and  down  in  the  common  bile-duct, 
is  to  be  differentiated  from  obstructive  jaundice  due  to 
compression  of  the  ducts  by  tumor — e.  g.,  of  head  of  the 
pancreas,  of  the  pylorus,  etc.  With  cholelithiasis  the  gall- 
bladder is  usually  contracted,  the  icterus  varies  in  intensity, 
the  stools  are  at  times  brown,  then  white,  the  spleen  is 
slightly  enlarged,  and  there  is  a  history  of  colicky  pain  and 
intermittent  fever.  With  tumor  compressing  the  duct  the 
gall-bladder  is  distended,  the  icterus  grows  constantly  deeper, 
and  the  stools  are  continuously  white;  colic,  fever,  and 
enlargement  of  the  spleen  are  absent. 

These  points  of  difference,  designated  as  Courvoisier's 
law,  are  not  always  sufficient  to  establish  a  diagnosis.  In 
the  doubtful  cases  an  exploratory  incision  should  be  made 
if  the  patient's  condition  warrants  it.  It  is  to  be  remembered 
that  carcinoma  quite  often  develops  secondarily  to  calculous 
disease  of  the  gall-bladder  and  ducts. 

The  chills  and  fever  and  enlarged,  tender  liver  due  to 
cholangitis  may  simulate  pysemic  abscesses  of  this  organ  with 
pylephlebitis.  The  history  of  an  intraperitoneal  suppuration 
or  ulceration  will  favor  a  pylephlebitis,  while  a  gallstone 
history  will  point  to  cholangitis. 


CARCINOMA  OF  THE  GALL-BLADDER. 

Malignant  disease  of  the  gall-bladder  frequently  develops 
after  long-standing  cholelithiasis.  It  appears  as  a  hard, 
irregular,  rapidly  growing  tumor  at  the  site  of  the  gall- 
bladder. The  patient  emaciates  rapidly,  ascites  develops 
early  and  especially  if  the  glands  at  the  portal  fissure  of  the 
liver  are  enlarged  and  press  upon  and  occlude  the  portal 
vein.    The  cystic  and  common  bile-ducts  become  obstructed, 


DISEASES  OF   THE  GALL-BLADDER  323 

with   consequent   icterus,    acholic   stools,    and   more   rapid 
emaciation  and  fever. 

The  differential  diagnosis  from  cholelithiasis  is  to  be  made 
from  the  hardness  and  irregularity  of  the  tumor,  the  icterus, 
cachexia,  and  ascites.  Unless  the  carcinoma  follows  chole- 
lithiasis, there  are  usually  no  colicky  pains. 


CARCINOMA  OF  THE  BILE-DUCTS. 

The  usual  sites  of  this  affection  are  either  at  the  papilla 
of  Vater  or  at  the  cystic  and  hepatic  junction.  According 
to  Courvoisier's  law  the  gall-bladder  becomes  distended;  the 
icterus  appears  slowly,  but  grows  steadily  deeper.  The  pain 
is  slight,  the  liver  is  enlarged,  and  finally  becomes  the  seat  of 
biliary  cirrhosis.     There  is  rapid  emaciation  and  ascites. 

The  differential  diagnosis  from  impacted  calculus  in  the 
choledochus  is  made  according  to  Courvoisier's  law;  colicky 
pain  and  fever  and  enlarged  spleen  being  absent,  and  the 
gall-bladder  being  distended. 


CHAPTER   XXX. 

DISEASES  OF  THE  PANCREAS. 

The  pancreas  lies  transversely  across  the  abdomen  behind 
the  peritoneum,  at  the  level  of  the  body  of  the  first  lumbar 
vertebra.  If  the  organ  is  enlarged  upward  it  pushes  the 
retroparietal  peritoneum  and  the  gastrohepatic  ligament 
forward  and  approaches  the  anterior  abdominal  wall  between 
the  liver  and  the  lesser  curvature  of  the  stomach;  if  the 
enlargement  is  forward  it  pushes  the  stomach  upward,  the 
transverse  mesocolon  downward,  and  the  gastrocolic  liga- 
ment forward,  and  appears  between  the  stomach  and  colon; 
and  if  the  enlargement  is  downward  it  separates  the  layers  of 
the  transverse  mesocolon  and  appears  below  the  transverse 
colon,  being  covered  by  the  great  omentum.  Should  the 
enlargement  downward  be  very  marked,  the  descending 
colon  would  thereby  be  raised  up  from  the  posterior  abdom- 
inal wall.  Enlargements  of  the  pancreas  are  due  chiefly  to 
cysts,  neoplasms,  and  inflammation. 

Our  appreciation  of  the  clinical  manifestations  of  pan- 
creatic disease  and  neoplasms,  and  our  ability  to  recognize 
these  conditions  have  been  materially  advanced  by  the 
experimental  labors  and  researches  of  Fitz,  Korte,  Mikulicz, 
Opie,  Mayo  Robson  and  others;  and  while  we  are  still  far 
from  being  able  to  make  a  certain  diagnosis  of  these  mal- 
adies, we  are  nevertheless  in  a  position  to  suspect  their 
presence,  and  if  we  exclude  the  diseases  which  in  their 
clinical  course  and  symptomatology  resemble  the  disorders 
of  this  organ,  we  will  be  able  in  many  cases  to  arrive  at  a 
correct  diagnosis. 

There  is  one  characteristic  lesion  of  the  acute  hemor- 
rhagic, gangrenous  and  some  of  the  more  chronic  diseases  of 
the  pancreas,  and  that  is  spots  of  necrosis  in  the  fat  surround- 
ing the  organ,  in  the  fat  of  the  omentum,  and  also,  though 


DISEASES  OF   THE  PANCREAS  325 

with  less  frequency,  in  the  subpleural  and  subpericardial  fat. 
These  spots  are  small,  opaque,  and  white,  and  are  probably 
due  to  a  diffusion  of  the  pancreatic  secretion  with  its  fat- 
splitting  ferment  into  the  surrounding  tissue/  Unfortunately, 
we  are  not  able  to  recognize  this  fat  necrosis  before  opening 
the  abdomen,  but  we  should  not  neglect  to  look  for  it  in  all 
doubtful  cases  of  abdominal  disease  when  the  abdomen  has 
been  opened,  and  if  it  is  present  we  may  be  assured  that  a 
grave  disease  of  the  pancreas  is  present. 

INFLAMMATION  OF  THE  PANCREAS. 

Acute  Inflammation. — The  onset  and  course  of  pancreatic 
hemorrhage,  acute  hemorrhagic  pancreatitis,  and  necrosis  of 
the  gland  are  eminently  acute  and  rapid.  The  presence  of  these 
maladies  should  always  be  suspected  where,  with  a  previous 
history  of  gallstone  disease  or  gastrointestinal  disorders, 
there  is  a  sudden  onset  of  severe  epigastric  pain,  vomiting, 
constipation,  abdominal  distention  and  extreme  prostration, 
with  rapid  pulse  and  normal  or  moderately  elevated  temper- 
atures. Opie  considers  that  these  three  conditions  are 
different  grades  and  stages  of  the  same  pathological  process, 
and  that  they  are  due  to  the  action  of  irritating  and  destructive 
agents,  chief  among  which  is  the  bile,  upon  the  gland.  This, 
he  believes,  gains  access  to  the  gland  when  the  papilla  of 
Vater  is  obstructed  by  a  calculus  that  is  large  enough  to 
occlude  the  orifice  of  the  latter  and  so  prevent  the  entrance 
of  the  bile  into  the  intestine,  but  is  not  of  sufficient  size  to 
completely  fill  the  ampulla  of  the  common  bile  and  pancre- 
atic ducts,  and  so  prevent  the  reflux  of  bile  along  the  pan- 
creatic duct  into  the  pancreas.  The  significance  of  a  history 
of  gallstone  disease  in  connection  with  the  acute  forms  of 
pancreatitis  will  according  to  this  be  appreciated. 

The  onset  and  initial  symptoms  of  acute  intestinal  obstruc- 
tion and  of  acute  appendicitis  resemble  very  much  those 
which  attend  these  forms  of  acute  pancreatitis.  But  the 
initial  prostration  is  much  more  intense  in  the  latter  affection. 

1  The  extent  of  the  diffusion  depends  on  the  duration  of  life  after  the  onset  of  the 
pancreatic  disease. 


326     INJURIES  AND  DISEASES  OF   THE   ABDOMEN 

With  intestinal  obstruction  there  is  absolute  constipation 
and  persistent  vomiting,  whereas  in  acute  pancreatitis  high 
enemata  withdraw  foul  gases  and  even  fecal  particles  from 
the  bowel.  With  acute  appendicitis  the  pain  in  the  beginning 
of  the  attack  is  centred  around  the  umbilicus  or  is  general 
in  the  abdomen,  and  later  becomes  localized  in  the  right  iliac 
fossa,  and  the  right  rectus  muscle  is  rigid;  while  with  acute 
pancreatitis  the  pain  at  the  outset  is  in  the  epigastrium, 
which  region  is  tender  and  rigid.  A  history  of  gallstone 
disease  would  speak  in  favor  of  acute  pancreatitis. 

Should  the  patient  survive  this  acute  stage  of  the  disease, 
he  would  then  go  on  to  present  the  evidences  of  a  pancreatic 
hemorrhage  and  necrosis.  With  local  necrosis  and  with 
complete  sequestration  of  the  gland  the  course  is  subacute, 
and  is  marked  by  moderate  elevations  of  temperature,  occa- 
sional vomiting,  constipation,  free  fluid  in  the  abdomen, 
emaciation,  loss  of  strength  and  bronzing  of  the  skin,  and 
by  the  appearance  of  a  swelling  in  the  epigastric  region 
corresponding  to  the  position  of  the  pancreas.  This  swelling 
is  retrogastric  and  has  no  respiratory  mobility,  and  is  tender 
and  smooth.  If  this  swelling  breaks  down  into  pus,  the  latter 
may  gravitate  downward,  especially  to  the  left,  or  more 
rarely  between  the  layers  of  the  transverse  mesocolon. 

Such  a  swelling  may  be  mistaken  for  a  neoplasm  on  the 
posterior  wall  of  the  stomach,  but  the  clinical  history  is 
entirely  different  in  these  two  affections,  and,  furthermore, 
the  lack  of  respiratory  mobility  of  the  tumor,  and  the  absence 
of  any  marked  change  in  the  chemical  composition  of  the 
gastric  juice,  together  with  the  absence  of  cachexia,  readily 
enable  us  to  exclude  a  gastric  new-growth. 

A  less  intense  onset  of  epigastric  pain,  nausea,  vomiting 
and  constipation,  and  a  more  subacute  course  which  is 
marked  by  moderate  fever,  emaciation,  occasional  vomiting, 
abdominal  distention,  constipation,  the  development  of  free 
ascites,  and  by  the  appearance  of  a  tender  swelling  in  the 
epigastrium  characterize  the  acute  suppurative  forms  of  pan- 
creatitis. The  swelling  is  retrogastric,  has  no  respiratory 
mobility,  and  is  very  tender.  The  leukocytes  are  increased 
in  number.  A  history  of  preceding  gallstone  disease  is  also 
suggestive  of  this  form  of  pancreatitis,  for  the  infection  of 


DISEASES  OF   THE  PANCREAS  327 

the  bile-ducts  that  is  so  commonly  present  with  biliary 
lithiasis  is  quite  likely  to  extend  up  into  the  radicles  of  the 
pancreatic  ducts. 

Chronic  Inflammation. — The  forms  of  chronic  imflamma- 
tion  of  the  pancreas  that  are  attended  with  enlargement  of 
the  head  of  the  organ  are  especially  important  diagnostically 
because  of  the  resemblance  their  clinical  manifestations  bear 
to  malignant  disease  of  the  pancreas,  pylorus,  duodenum,  and 
gall-bladder. 

In  all  of  these  affections  the  patients  complain  of  gastro- 
intestinal disturbances,  such  as  nausea,  vomiting,  and  consti- 
pation; they  are  emaciated  and  usually  icteric,  and  on  exami- 
nation we  find  a  hard,  nodular  tumor,  somewhat  to  the  right 
of  the  epigastrium,  and  if  the  patient  is  icteric  a  distention 
of  the  gall-bladder  is  present. 

Evidences  of  disturbed  gastric  motility,  such  as  dilatation 
of  the  stomach,  prolongation  of  the  time  the  organ  requires 
for  emptying  itself  after  a  meal,  and  stagnation  of  the  con- 
tents within  the  stomach,  combined  with  an  absence  of  free 
hydrochloric  acid  and  ferments  from  the  gastric  juice,  and 
the  presence  of  lactic  acid  therein,  enable  us  to  distinguish 
neoplasms  of  the  pylorus  and  duodenum  from  pancreatic 
tumors.  The  more  superficial  location  of  the  tumor  and  an 
earlier  appearance  of  icterus  help  to  differentiate  the  neo- 
plasms of  the  gall-bladder.  But  the  tumor  which  is  due  to 
carcinoma  of  the  head  of  the  pancreas  cannot  in  most 
instances  be  differentiated  from  that  due  to  a  chronic  inflam- 
mation of  this  part  of  the  organ  without  the  aid  of  exploratory 
laparotomy,  and  in  quite  a  number  of  cases  the  surgeon  is 
unable  to  decide  between  the  two  affections  even  when  he 
has  the  parts  directly  accessible  to  inspection  and  palpa- 
tion. 

The  presence  of  sugar  in  the  urine  and  of  fat  in  the  stools 
is  an  infrequent  occurrence  in  these  forms  of  pancreatic  dis- 
ease, but  when  they  do  exist  they  afford  additional  evidences 
of  such  malady. 

The  differentiation  of  tumors,  especially  those  of  the  pan- 
creas that  cause  obstructive  jaundice  from  biliary  lithiasis 
with  obstructive  jaundice,  has  already  been  considered.  (See 
pp.  310  and  324.) 


328     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 


TUMORS  OF  THE  PANCREAS. 

Cysts. — A  pancreatic  cyst  manifests  itself  by  the  symp- 
toms of  gastric  catarrh — ^viz.,  loss  of  appetite,  nausea,  vom- 
iting of  gastric  and  biliary  matter  or  of  blood,  constipation 
or  diarrha^a,  together  with  the  presence  of  a  retroperitoneal 
tumor  that  is  tense  and  fluctuating,  but  not  tender,  that 
usually  has  no  respiratory  mobility,  and  that  has  definite 
and  special  relations  to  the  stomach  and  transverse  colon. 
These  tumors  are  of  slow  growth  and  the  gastric  disturb- 
ances may  exist  for  some  time  prior  to  the  development  of 
a  palpable  tumor. 

Fig. 133 


A  pancreatic  cyst,  type  C.    (Flaischlen.) 

The  relation  which  the  cyst  bears  to  the  stomach  and 
transverse  colon  is  its  important  and  distinguishing  char- 
acteristic. At  first  it  is  retroperitoneal  and  usually  lies  be- 
hind the  stomach;  as  it  grows  it  may  project  upward,  push 
the  hepatogastric  ligament  (lesser  omentum)  forward,  and 
approach  the  anterior  abdominal  wall  above  the  lesser  cur- 
vature of  the  stomach  (type  A).  Larger  cysts  of  this  class 
drop  down  in  front  of  the  stomach,  and  in  .thei?  g-niterior  gas- 


DISEASES  OF   THE  PANCREAS 


329 


trie  portion  they  enjoy  considerable  respiratory  mobility.    A 
second  class  of  cysts  (type  B)  push  directly  forward  between 


Fig. 134 


Cyst  of  the  pancreas  developing  between  the  si.j.nach  and  liver,  type  A.  The  lesser 
omentum,  and  possibly  the  foramen  of  Winslow,  is  crowded  forward  by  the  cyst. 
(Von  Bergmann.) 

the  stomach  and  transverse  colon,  being  covered  by  the  gastro- 
colic ligament;  and  a  third  class  (type  C)  bulge  downward, 


330     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

pushing  the  lower  layer  of  the  transverse  mesocolon  down- 
ward, and  appearing  below  the  transverse  colon,  being 
covered  by  the  greater  omentum.     These  relations  of  the 

Fig. 135 


Showing  the  relations  of  the  liver,  stomach,  and  transverse  colon  to  a  cyst  of  the  pan- 
creas, type  A.   The  stomach  lies  in  front  of  and  below  the  cyst.  (Von  Bergmann.) 


tumor  to  the  stomach  and  transverse  colon  are  so  important 
for  establishing  a  diagnosis  that  we  should  never  neglect  in 
cases  of  abdominal  cystic  tumors  to  distend  both  these  vis- 
cera and  determine  their  position  in  reference  to  the  growth. 


DISEASES  OF   THE  PANCREAS 


331 


The  presence  of  undigested  proteid  matter  or  of  fat  in 
the  stools,  or  the  presence  of  sugar  in  the  urine  are  to  be 


Fig. 136 


Liver. 


Cyst  of  the  pancreas  developing  between  the  stomach  and  transverse  colon,  type  B. 
The  gastrocolic  omentum  lies  in  front  of  the  cyst.    (Von  Bergmann.) 

looked  upon  as  confirmatory  evidences  of  a  pancreatic  cyst. 
Their  absence  does  not  speak  against  the  cyst  being  of  pan- 
creatic origin. 


332     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

Disturbances  of  gastric  motility  leading  to  dilatation  of 
the  organ  and  stagnation  within  it,  or  the  evidences  of 
obstructive  jaundice,  hydronephrosis  or  ascites,  are  the  con- 

FiG. 137 


Showing  the  relations  of  the  liver  and  transverse  colon  to  the  tumor  caused  by  a 
typical  pancreatic  cyst,  type  B.  The  stomach  is  displaced  upward  and  partially  over- 
laps the  cyst.    The  transverse  colon  follows  its  lower  margin.    (Von  Bergmann.) 


sequences  of  pressure  exercised  by  any  large  abdominal 
tumor  upon  the  stomach,  the  common  bile-duct,  the  ureter 
or  the  portal  vein;  these  symptoms  do  not  indicate  the  pan- 
creatic origin  of  a  tumor. 


DISEASES  OF   THE  PANCREAS 


333 


The  composition  of  the  cyst  contents  will  help  to  dif- 
ferentiate  cystic    tumors    that    are    surrounded    by   such 


Fig. 138 


Lower  layer 
of  transverse 
mesocolon. 


Cyst  of  the  pancreas  developing  between  the  layers  of  the  transverse  mesocolon, 
type  C,  and  stretching  the  lower  layer  more  than  the  upper.    (Von  Bergmann.) 


dense  adhesions   as  to  make  their  origin  uncertain,   even 
after  the  abdomen  has  been  opened.    These  cyst  contents  are 


334     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

cloudy,  brownish  in  color,  of  syrupy  consistency,  occasionally 
colloid  or  purulent.  They  are  usually  mixed  with  some  fluid 
or  clotted  blood;  they  are  alkaline,  of  1007  or  1028  specific 


Fig. 139 


Cyst  absolute 
dulness. 


Cyst  relative 
dulness. 


Showing  the  relations  of  the  liver,  stomach,  and  transverse  colon  to  a  pancreatic 
cyst  of  type  C.  The  transverse  colon  lies  in  front  of  the  cyst  or  along  its  upper 
border.    (Von  Bergmann.) 

gravity,  have  some  albumin,  rarely  any  sugar,  and  some- 
times cholesterin.  Ferments  are  not  always  present;  some- 
times there  is  diastase,  and  again  trypsin  and  steapsin. 


DISEASES  OF   THE  PANCREAS 


335 


The  cause  underlying  the  formation  of  a  pancreatic  cyst 
is  often  to  be  gleaned  from  the  previous  history  of  the  patient. 
Thus  trauma,  or  the  acute  infectious  diseases,   or  chole- 


FiG. 140 


Liver. 


Stomach. 


Cyst. 
■ Transverse  colon 


Cyst  of  the  pancreas  developing  between  the  layers  of  the  transverse  mesocolon. 
The  colon  lies  directly  in  front  of  the  cyst.    (Von  Bergmann.) 


lithiasis  or  hemorrhage  into  the  pancreas  are  the  most 
frequent  causes,  and  in  most  instances  the  patient  will  give 
a  history  of  trauma  or  present  the  evidences  of  the  previous 
or  present  existence  of  these  maladies.    A  chronic  pancreatitis 


336     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

or  an  obstruction  of  the  duct  of  Wirsung  by  a  calculus  that 
has  formed  within  it  are  less  frequent  causes  for  pancreatic 
cysts.  The  symptoms  afforded  by  pancreatic  calculi  would 
not  differ  in  any  way  from  those  of  biliary  calculi. 

Pedunculated  cystic  tumors  of  the  liver,  and  especially  the 
echinococcus  cysts,  are  distinguished  from  pancreatic  cysts 
in  that  they  have  respiratory  and  independent  mobility  and 
lie  in  front  of  the  stomach,  whereas  the  pancreatic  cysts  lie 
behind  or  above  or  below  this  organ.  Liver  cysts  remain 
attached  to  the  liver  even  when  the  patient  assumes  the 
upright  position,  whereas  pancreatic  cysts  fall  away  from  it. 
When  it  is  impossible  to  make  the  differentiation  it  is  better 
to  make  an  exploratory  incision  than  an  exploratory  puncture. 

A  hydrops  of  the  gall-bladder  is  distinguished  from  a  pan- 
creatic cyst  by  the  pear-shape  of  the  tumor,  its  proximity  to 
the  abdominal  wall,  and  its  free  mobility.  It  is  attached  to 
the  liver  and  lies  to  the  right  and  in  front  of  the  stomach, 
whereas  pancreatic  cysts  lie  behind  the  stomach. 

Splenic  tumors  are  differentiated  from  cysts  in  the  tail  of 
the  pancreas  by  their  characteristic  splenic  shape,  their 
notched  border,  and  by  their  pushing  the  stomach  and  colon 
to  the  left. 

Aortic  aneurysms  are  distinguished  by  their  expansile 
pulsation  and  systolic  murmur.  We  must  note,  however, 
that  a  pulsation  and  murmur  are  to  be  heard  over  any  abdom- 
inal tumor  that  compresses  or  lies  upon  the  aorta;  such 
pulsation,  however,  is  not  expansile. 

A  hydro-  or  pyonephrosis  differs  from  a  pancreatic  cyst  in 
that  it  occupies  the  loin,  with  the  distended  colon  lying  in 
front  and  to  its  inner  side;  when  the  tumor  is  very  large, 
the  colon  lies  to  its  outer  side.  Cysts  lie  below  or  above  the 
colon.  Furthermore,  in  kidney  disease  cystoscopic  exami- 
nation reveals  changes  in  the  ureteral  mouth,  and  the  urine 
which  is  drawn  by  ureteral  catheterization  from  the  corre- 
sponding kidney  will,  as  a  rule,  show  abnormalities.  The 
patient  is  also  apt  to  suffer  from  urinary  disturbances. 

Mesenteric  cysts  usually  lie  below  the  umbilicus;  ovarian 
cysts  grow  from  below,  and  by  vaginal  or  rectal  palpation 
we  can  feel  the  pedicle  that  connects  them  to  the  ovary.  In 
either  case  the  relations  of  the  stomach  and  colon  to  the 


DISEASES  OF   THE  PANCREAS  337 

tumor  will   usually  enable   us   to  differentiate  them  from 
pancreatic  cysts. 

Malignant  growths  of  the  pancreas  are  distinguished  from 
cysts  by  their  hardness,  irregularity,  and  rapid  growth;  they 
are  furthermore  attended  with  cachexia  and  do  not  fluctuate. 
Chronic  abscesses  of  the  pancreas  are  more  tender  than 
cysts,  and  are  accompanied  by  fever  and  emaciation.  Their 
course  is  much  more  rapid. 


MALIGNANT  TUMORS  OF  THE  PANCREAS. 

The  evidences  afforded  by  a  malignant  growth  (usually  car- 
cinoma) of  the  head  of  the  pancreas  are  a  tender,  hard, 
smooth  or  irregular  tumor  to  the  right  of  the  vertebral  column 
and  behind  the  stomach,  together  with  epigastric  pain,  early 
cachexia,  and  ascites.  Obstructive  jaundice  from  compres- 
sion of  the  choledochus  develops  in  most  cases,  and  when  it 
does  the  gall-bladder  is  felt  to  be  distended.  Glycosuria  and 
fat  in  the  stools   are  much  less  frequent  symptoms. 

The  absence  of  a  palpable  tumor  and  the  paucity  of  the 
physical  sufferings  preclude  the  possibility  of  making  a 
diagnosis  during  the  early  stages  of  the  disease.  Many  of 
these  patients  first  present  themselves  to  the  physician  when 
they  become  jaundiced,  and  at  such  a  time  the  differentiation 
must  be  made  between  obstructive  jaundice  due  to  biliary 
calculi,  and  that  due  to  chronic  inflammatory  and  malignant 
disease  of  the  pancreas. 

With  calculous  disease  there  is  a  preceding  history  of 
cholecystitic  pain,  biliary  colic,  attacks  of  jaundice,  and, 
possibly,  temperature  elevations.  The  gall-bladder  is  tender 
and  cannot,  as  a  rule,  be  palpated,  and  the  liver  and  spleen 
are  enlarged.  While  the  patients  are  much  emaciated,  they 
are  not  cachectic.     (See  Courvoisier's  law,  pp.  319-322.) 

The  chronic  inflammatory  forms  of  pancreatitis  cannot 
with  any  degree  of  certainty  be  differentiated  from  malig- 
nant disease  of  the  organ  even  when  the  abdomen  has  been 
opened  and  the  parts  are  directly  accessible  to  palpation.  An 
absence  of  cachexia  and  the  existence  of  fever  speak  for 
chronic  pancreatitis;  ascites  is  indicative  of  carcinoma. 

22 


338     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

Cancer  of  the  pylorus  is  to  be  distinguished  from  cancer 
of  the  pancreas-head  by  the  disturbed  gastric  motiHty  and 
the  chemical  changes  in  the  gastric  secretion — viz.,  an  absence 
of  free  hydrochloric  acid  and  ferments,  and  a  presence  of 
lactic  acid — that  attend  it. 

The  evidences  of  chronic  intestinal  stenosis,  erections  of 
the  colon,  and  dilatation  of  the  caput  coli  distinguish  colon 
cancers  from  neoplasms  of  the  pancreas. 

Cancer  of  the  papilla  of  Vater  or  of  the  choledochus  can 
only  be  differentiated  from  pancreatic  neoplasms  by  explo- 
ratory laparotomy. 

PANCREATIC  CALCULI. 

The  clinical  evidences  afforded  by  these  stones  are  scarcely 
different  from  those  which  are  occasioned  by  biliary  calculi. 
Glycosuria  and  fat  in  the  stools  speak  strongly  for  pancreatic 
as  against  biliary  calculi.  Should  a  history  of  colicky  pain 
in  the  epigastrium  precede  the  development  of  a  cystic  tumor 
of  the  pancreas,  the  chances  would  be  very  great  that  the 
latter  was  a  true  retention  cyst  from  obstruction  of  the  duct 
of  Wirsung  by  a  calculus. 


CHAPTER   XXXI. 

DISEASES  OF  THE  SPLEEN. 

The  spleen  normally  lies  in  the  left  hypochondrium.  It 
extends  from  the  ninth  to  the  eleventh  ribs,  its  long  axis  being 
parallel  to  the  tenth  rib.  Its  posterior  border  lies  near  to 
the  vertebral  column  and  its  anterior  border  reaches  to  the 
mid-  or  anterior  axillary  line. 

MOVABLE  SPLEEN. 

A  movable  spleen  manifests  itself  by  a  dragging  pain  in 
the  left  hypochondrium,  which  radiates  to  the  thigh,  and  by 
the  evidences  of  compression  of  the  neighboring  viscera — 
e.  g.,  strangury  from  compression  of  the  kidney,  constipation 
or  even  ileus  from  compression  of  the  intestine.  The  organ 
can  be  recognized  by  its  notched  anterior  border  and  hilus ; 
it  may  be  of  normal  size  or  it  may  be  considerably  enlarged 
— e.  g.,  from  malaria,  leukaemia,  or  neoplasm. 

A  floating  kidney  is  easily  differentiated  from  the  spleen 
because  it  has  not  the  splenic  shape  or  notched  anterior 
border. 

The  possibility  of  such  a  movable  organ  suffering  a  torsion 
of  its  pedicle  should  be  remembered,  so  that  the  pain  and 
peritonitis  to  which  this  accident  gives  rise  should  be  attrib- 
uted to  its  proper  cause. 

ABSCESS  OF  THE  SPLEEN. 

Abscess  formation  in  this  organ  is  to  be  suspected  if  it 
becomes  swollen  and  tender,  and  if  there  are  constitutional 


340     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

evidences  of  pus  accumulation.  Fluctuation  is  only  to  be 
elicited  in  the  large  abscesses.  The  acute  infectious  diseases, 
typhoid,  rheumatism,  and  pyaemia,  are  the  most  frequent 
causes  of  this  condition.  In  typhoid  the  presence  of  a 
splenic  abscess  should  be  suspected  if,  after  the  subsid- 
ence of  the  fever,  the  organ  becomes  swollen  and  tender 
and  the  fever  rises  again. 


RUPTURE  OF  SPLEEN. 

Rupture  of  the  spleen  is  predisposed  to  by  the  patho- 
logical conditions  of  the  organ  which  are  induced  by  ma- 
laria, typhoid  fever,  and  other  infectious  diseases,  and  is 
excited  by  trauma  and  forcible  contraction  of  the  abdominal 
muscles. 

The  symptoms  are  pain,  rigidity  of  the  abdominal  wall, 
and  internal  hemorrhage.  (For  the  diagnosis  of  this  accident 
see  Contusions  of  the  Abdomen,  p.  235.) 


NEOPLASMS  OF  THE  SPLEEN. 

The  benign  cystic  growths,  of  which  there  are  serous, 
hemorrhagic,  hydatid,  and  dermoid  varieties,  occasion  an 
enlargement  of  the  organ,  which  causes  pressure  upon  the 
neighboring  viscera.  Benign  solid  enlargements  of  the  spleen 
are  due  to  malaria  and  leukaemia;  these  two  conditions  are 
readily  differentiated  by  examination  of  the  blood  for 
Plasmodia  and  by  counting  the  leukocytes. 

Hydronephrotic  cystic  tumors  differ  from  splenic  cysts  in 
that  they  are  attended  with  a  history  of  urinary  disturbances, 
and  by  alterations  in  the  amount  and  character  of  the  urine 
coming  from  the  corresponding  kidney.  These  tumors, 
furthermore,  have  no  notched  anterior  border. 

Hydatid  cysts  of  the  tail  of  the  pancreas  are  to  be  differ- 
entiated from  splenic  cysts  by  the  characteristic  relation 
which  they  have  to  the  stomach  and  transverse  colon. 
Hydatid  cysts  of  the  left  lobe  of  the  liver  are  much  more 


DISEASES  OF   THE  SPLEEN 


341 


difficult  to  differentiate  from  splenic  tumors,  unless  a  tympan- 
itic zone  separates  the  liver  from  the  spleen. 

Ovarian  cysts  are  distinguished  from  splenic  cysts  by  their 
growth  from  below  upward,  and  by  their  connection  to  the 


Fig.  141 


Large  leuksemic  splenic  tumor.  Note  characteristic  notch  on  anterior  border, 
which  alone  is  sufficient  to  distinguish  a  splenic  tumor  from  all  other  abdominal 
swellings. 


ovary,  broad  ligaments,  and  uterus  with  a  pedicle  that  can 
be  palpated  through  the  vagina  or  rectum. 


342     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

A  rapid  enlargement  of  the  spleen  attended  with  pain  and 
cachexia,  occurring  in  a  young  individual  in  whom  leukaemia 


Fig. 142 


Large  splenic  tumor.     Note  characteristic  notch  and  sharp  anterior  border, 
(Winter.) 

has  been  excluded  by  a  blood  examination,  speaks  for  sarcoma 
of  the  organ. 


CHAPTER   XXXII. 

DISEASES  OF  THE  FEMALE  PELVIC  ORGANS. 

METHOD  OF  EXAMINATION. 

Abnormally  profuse  or  irregular  uterine  bleeding,  vaginal 
discharge,  pelvic  pain,  or  the  evidences  of  pressure  upon  the 
bladder,  rectum  or  ureter,  such  as  increased  frequency  of  or 
pain  on  urination,  and  constipation,  are  the  first  indications 
to  women  that  something  is  wrong  with  their  pelvic  organs. 
The  physician  to  whom  they  apply  should  in  every  case  take 
a  careful  history  (for  the  details  see  p.  18),  and  then  pro- 
ceed to  a  careful  abdominal  and  pelvic  examination. 

For  this  purpose  the  patient  should  be  placed  on  her  back 
transversely  across  the  bed  or  on  an  examining  couch,  with 
the  thighs  semiflexed  upon  the  abdomen  and  the  legs  flexed 
and  supported  by  an  assistant  or  by  leg  stirrups.  In  some 
special  instances  the  knee-chest  or  the  lateral  prone  (Sims') 
positions  may  be  employed.  The  bladder  should  be  evacu- 
ated prior  to  the  examination. 

The  external  genitals  and  the  anal  region  should  first  of 
all  be  inspected  and  note  taken  of  any  abnormalities  in  these 
parts.  Any  bulging  or  prolapse  of  the  vaginal  walls  or 
internal  genital  organs  on  coughing  or  straining,  the  appear- 
ance of  the  vaginal  mucosa  as  seen  through  a  speculum,  and 
of  the  uterine  cervix  and  os  should  also  be  noted.  The 
examiner  should  then  proceed  to  palpate  bimanually  through 
the  vagina  and  rectum  the  pelvic  organs,  uterus,  broad  liga- 
ment, ovaries  and  tubes,  parametria,  bladder,  and  rectum. 
In  thin  subjects  with  lax  abdominal  walls  the  Fallopian 
tubes  can  be  palpated  from  their  inner  uterine  end,  where 
they  feel  like  firm  cords  of  lead-pencil  thickness,  to  their 
outer  extremity,  where  they  are  intimately  related  to  the 
ovary.     The  consistency  of  the  cervix;  the  position,  size. 


344     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

flexure,  and  mobility  of  the  uterus;  the  presence  of  neo- 
plasms and  their  relation  to  the  uterus,  broad  ligaments,  and 
ovaries;  the  presence  of  exudates  and  their  relation  to  the 
uterus,  and  last,  but  not  least,  the  amount  of  pelvic  pain 
and  tenderness  the  abdominal  condition  provokes  should  all 
be  carefully  noted. 

Hegar  has  introduced  a  plan  which  is  very  useful  in 
detecting  the  connection  or  otherwise  of  a  tumor  with  the 
uterus  or  broad  ligament.  The  uterine  os  is  seized  with  a 
vulsella   forceps    and   drawn   downward,    and    the   forceps 

Fig. 143 


Hegar's  method  of  palpation  of  pedicle  ol'  uteiiue  or  ovarian  tumor.    (Winter.) 


placed  in  the  hands  of  an  assistant.  The  right  hand  is  laid 
upon  the  abdominal  wall  above  the  pubes  and  the  left  fore- 
finger passed  into  the  rectum.  The  tumor  being  outlined 
between  the  two,  is  drawn  upward;  if  it  has  any  connection 
with  the  uterus,  the  forceps  will  rise.  If  the  assistant  pulls 
gently  on  the  forceps  while  the  tumor  is  held  between  the 
two  hands  of  the  surgeon,  its  pedicle  can  usually  be  felt 
and  outlined  by  the  rectal  finger. 

The  abdominal  examination  should  determine  the  shape  of 
the  abdomen,  the  presence  of  undue  bulging  in  some  eccentric 
position,  the  retraction  or  protrusion  of  the  navel,  the  presence 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     345 

of  free  fluid  in  the  peritoneal  cavity,  the  presence  of  tumors, 
their  size  and  mobiHty,  and  finally  the  size  and  consistency 
of  the  liver  and  other  abdominal  organs. 

The  uterine  sound  affords  us  an  invaluable  means  of 
determining  the  length  of  the  uterine  canal  and  the  position 
of  the  uterus  with  reference  to  an  exudate  or  neoplasm  in  the 
pelvis.  It  goes  without  saying  that  a  uterine  sound  should 
never  be  introduced  until  we  have  done  our  utmost  to  ascer- 
tain that  the  woman  is  not  pregnant,  and,  further,  that  all 
aseptic  precautions  should  be  observed  in  its  introduction. 


FIBROMYOMATA  OF  THE  UTERUS. 

The  physical  complaints  that  lead  patients  with  fibro- 
myomata  of  the  uterus  to  apply  to  us  for  treatment  are 
menorrhagia,  metrorrhagia,  or  dysmenorrhoea,  or  attacks  of 
local  pelvic  peritonitis  provoking  nausea,  vomiting,  constipa- 
tion, intestinal  distention,  some  free  exudate  in  the  peritoneal 
cavity  and  pelvic  pain,  or  the  evidences  of  pressure  upon  the 
bladder,  rectum,  ureter,  pelvic  vessels  and  nerves,  such  as 
increased  frequency  of  urination,  pain  on  urination,  consti- 
pation, neuralgic  pain  in  the  pelvis  shooting  down  into  the 
lower  limbs,  swelling  and  congestion  of  the  feet  and  legs,  or 
sterility.  By  this  it  is  not  meant  to  imply  that  all  those  who 
have  fibroid  tumors  of  the  uterus  necessarily  suffer  from  one 
or  more  or  all  of  these  symptoms,  for  even  fairly  large  fibroids 
may  be  present  and  not  give  rise  to  any  disturbances.  The 
examination  of  these  patients  reveals  conditions  that  vary 
according  as  the  tumor  is  submucous,  intramural  or  sub- 
peritoneal, and  according  to  its  location  on  the  uterine 
wall. 

Submucous  Fibromata. — Submucous  fibromata  are  to  be 
detected  only  when  they  protrude  as  polypi  through  the 
cervix,  or  when  they  can  be  palpated  by  inserting  the  finger 
through  the  cervix  into  the  uterine  cavity.  The  presence 
of  other  fibroid  masses  in  the  wall  of  or  beneath  the  peri- 
toneal coat  of  the  uterus  usually  enables  us  to  make  the 
correct  diagnosis.  These  are  the  tumors  that  occasion  the 
most  profuse  uterine  bleedings,  especially  at  the  menstrual 


346     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

periods.  The  introduction  of  the  sound  affords  impor- 
tant data  for  the  diagnosis,  for  the  uterine  canal  in  these 
cases  is  found  distorted  and  usually  somewhat  lengthened. 
As  a  rule,  such  submucous  tumors  tend  eventually  to  pro- 
trude through  the  cervical  canal,  and  in  some  instances 
spontaneous  delivery  takes  place.  If  the  latter  occurs 
the  tumor  which  presents  in  the  vagina,  if  of  large  size, 
may  feel  like  a  presenting  fetal  head,  and  may  give  one 
the  impression  that  labor  is  going  on.  The  impression  is 
quickly  dispelled  if  palpation  of  the  abdomen  reveals  no 
fetal  parts,  if  on  auscultation  no  fetal  heart  sounds  are  to 
be  heard,  and  if  there  are  no  signs  of  pregnancy  in  the 
breasts,  etc. 

Smaller  tumors  that  present  in  or  that  have  passed  through 
the  cervix  appear  as  smooth,  rounded  or  pear-shaped  or 
cylindrical  masses,  the  mucous  membrane  over  which  is 
either  intact  or  ulcerated. 

The  bleeding  which  attends  submucous  fibroids  is  often 
very  suggestive  of  abortion.  The  latter  is,  however,  accom- 
panied by  the  usual  signs  of  early  pregnancy  and  by  the 
presence  of  placental  tissue  in  the  discharge.  All  doubt  as 
to  the  diagnosis  is  at  once  dispelled  if,  when  the  finger  is 
introduced  into  the  uterus,  a  firm  mass  of  varying  size  and 
shape,  covered  with  smooth  or  ulcerated  mucous  membrane, 
is  to  be  felt. 

Intramural  Fibromata. — Intramural  fibromata  are  much 
easier  to  detect  after  they  have  reached  a  palpable  size. 
They  enlarge  and  thicken  the  uterus,  which  has  an  irregular, 
smooth,  nodular  shape,  and  elongate  and  distort  the  uterine 
canal.  The  size  of  the  nodules  vary;  they  are  of  very  slow 
growth,  and  though  the  patients  may  become  very  weak 
and  anaemic,  they  are  not  cachectic. 

Such  fibroids  may  give  one  the  impression  of  a  sarcoma, 
but  their  multiple  character,  their  slow  growth,  and  the 
absence  of  cachexia  serve  to  differentiate  them  from  this 
condition.  The  possibility  of  a  sarcomatous  degeneration  of 
the  fibroids  taking  place  should  not  be  forgotten.  This 
would  be  indicated  by  a  suddenly  assumed,  much  more  rapid 
growth  of  the  tumor,  by  increased  pain  and  bleeding,  and 
by  emaciation;  these  latter  symptoms  are  much  more  signifi- 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     347 

cant  if  they  occur  after  the  menopause,  when  fibroid  tumors 
should  under  natural  conditions  gradually  shrink. 

Subperitoneal  Fibroids. — The  subperitoneal  fibroids  are 
readily  recognized  from  their  smooth,  rounded,  hard,  non- 
tender,  and  multiple  character.  They  move  with  the  uterus; 
if  they  are  pedunculated  they  enjoy  considerable  independent 
mobility,  but  otherwise  they  are  fixed  to  the  uterus.  Those 
which  are  located  at  the  fundus  of  the  uterus  grow  upward 
into  the  abdominal  cavity;  those  which  spring  from  its  sides 
push  apart  the  layers  of  the  broad  ligament  and  with  con- 
tinued growth  raise  up  the  retroparietal  peritoneum,  and 
thus  come  to  lie  intraligamentously  or  subcsecally  or  sub- 
sigmoidally. 

They  must  be  distinguished  from  ovarian  and  tubal 
enlargements.  Ovarian  tumors  can  be  traced  to  this  organ. 
They  are  usually  cystic  and  fluctuating,  or  if  solid  they  are 
softer  than  fibroids.  They  rarely  cause  uterine  bleeding,  and 
never  elongate  or  distort  the  uterine  canal.  Their  base  is 
external  to  the  round  ligament.  Tubal  swellings  are  con- 
nected by  a  narrow  isthmus  with  the  cornu  of  the  uterus. 
They  are  tender,  of  sausage-shape,  and  tend  to  prolapse 
behind  the  uterus,  where  they  become  adherent.  Their 
development  is  preceded  by  a  history  of  genital  infection, 
either  septic  or  gonorrhoeal  or  tuberculous.  They  rarely  cause 
much  bleeding,  and  never  elongate  or  distort  the  uterine 
canal.  Intraperitoneal  haimatocele  and  pelvic  hcematoma  are 
distinguished  from  uterine  fibroids  by  the  fact  that  they 
usually  follow  a  tubal  pregnancy,  a  history  of  which  can  be 
elicited  on  cross-questioning.  These  tumors  are  soft  at  first 
and  gradually  become  harder;  they  are  adherent  and  tender 
and  have  ill-defined  outlines. 

Other  intra-abdominal  tumors  located  in  the  upper  seg- 
ment of  this  cavity  are  distinguished  from  pedunculated 
uterine  myomata  in  that  they  fall  away  from  the  pelvic 
organs  when  the  patient  is  placed  in  Trendelenburg's 
position. 

Ballottement,  swelling  of  the  breasts,  morning  nausea  and 
vomiting,  fetal  heart  sounds,  and  amenorrhea  readily  dis- 
tinguish a  pregnant  uterus  from  one  that  is  the  seat  of  a 
large,  succulent  fibroid  tumor. 


348     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

A  bicornate  uterus  may  to  palpation  feel  like  a  uterus 
with  a  fibroid  at  one  cornu.  The  possibility  of  introducing 
the  sound  into  two  canals  and  the  relation  of  the  round 
ligaments  to  the  uterus  are  the  only  data  we  have  for  a  differ- 
ential diagnosis. 


MALIGNANT  NEOPLASMS  OF  THE  UTERUS. 

When  a  woman  at  the  menopause  commences  to  flow 
irregularly  and  profusely,  and  has  a  foul,  watery,  or  purulent 
vaginal  discharge,  she  should  not  be  considered  as  following 
the  normal  course  at  this  period,  but  she  should  be  strongly 
suspected  of  having  a  carcinoma  of  the  uterus.  Not  until  a 
careful  examination  has  shown  that  no  cancer  is  present 
should  we  dismiss  this  suspicion,  and  even  then  it  is  best 
to  keep  such  a  patient  under  close  observation  for  some 
time. 

An  epithelioma  of  the  cervix  first  appears  as  an  indurated 
or  infiltrated  area,  the  rest  of  the  cervix  having  a  glazed 
or  granular  appearance.  It  soon  forms  a  cauliflower-like 
growth  which  fills  the  vaginal  vault  and  tends  to  ulcerate, 
leaving  an  indurated,  sloughing  ulcer,  with  everted  edges. 

Adenocarcinoma  of  the  cervix  first  appears  as  a  nodule, 
which  grows  rapidly,  invades  the  vaginal  surface  of  the  cervix, 
and  forms  a  cauliflower,  villous  mass  that  resembles  an 
epithelioma. 

Adenocarcinoma  of  the  body  of  the  uterus  appears  as  a 
papillary,  dendritic  growth  and  causes  an  enlargement  of  the 
organ.  If  there  is  any  doubt  as  to  the  diagnosis,  a  section  of 
the  cervix  or  scrapings  from  the  uterine  body  should  be  sent 
to  the  pathologist  for  microscopic  examination. 

The  clinical  evidences  of  sarcoma  are  similar  to  those  of 
carcinoma;  they  can  be  differentiated  only  by  microscopic 
examination.  The  possibility  of  a  sarcomatous  degeneration 
of  benign  myomata  should  be  kept  in  mind,  and  if  a  previously 
benign  tumor  takes  on  a  very  rapid  growth,  bleeds  profusely, 
and  causes  considerable  pain,  this  condition  should  be 
suspected. 


DISEASES  OF  THE  FEMALE  PELVIC  ORGANS     349 


INFLAMMATIONS  OF  THE  FALLOPIAN  TUBES. 

When  the  Fallopian  tube  becomes  inflamed  its  outer  end 
becomes  closed  by  the  adhesions  which  form  between  it  and 
the  ovary,  omentum,  or  intestine,  or  by  the  adhesion  of  its 
own  fimbriae  to  one  another.  The  cavity  of  the  tube  then 
becomes  distended  with  inflammatory  products,  and  owing 
to  its  increased  weight  the  organ  falls  down  into  Douglas' 
space,  where  it  becomes  adherent.  The  early  formation  of 
adhesions  to  the  lateral  or  posterior  pelvic  floor  prevents  this 
prolapse  into  Douglas'  cul-de-sac,  and  in  such  cases  the 
distended  tube  bulges  downward,  separates  the  layers  of  its 
mesentery  and  those  of  the  broad  ligament,  and  thus  come 
to  lie  in  an  intraligamentous  position.  The  presence  of 
adhesions  and  parametritis  often  make  it  difiicult  to  decide 
whether  the  tube  is  intraperitoneal  or  intraligamentous. 

The  distal  two-thirds  of  the  tube  is  the  usual  site  of  disease. 
Inflammation  of  the  tubes  is  excited  by  infection  with  the 
gonococcus,  tubercle  bacillus,  bacillus  actinomycosis,  pyogenic 
organisms,  etc. 

The  terminations  hydro-,  or  pyo-,  or  hyematosalpinx  indi- 
cate a  distention  of  the  tube  with  serum,  or  pus,  or  blood. 

The  milder  forms  of  salpingitis  (catarrhal  and  hydrosal- 
pinx), and  even  some  of  the  cases  of  pyosalpinx,  give  rise 
only  to  distention  of  the  tube  and  the  feeling  of  pelvic  weight 
and  tension. 

The  severer  forms,  and  especially  the  cases  of  pyosalpinx, 
manifest  themselves  by  recurring  attacks  of  pelvic  pain  and 
tension,  fever,  nausea,  vomiting,  and  meteorism.  The  attacks 
may  recur  very  frequently,  and  between  them  the  patient 
suffers  from  pelvic  weight  and  vesical  or  rectal  disturbances. 
In  the  purulent  forms  the  patient  may  develop  chronic 
sepsis,  with  fever,  emaciation,  and  secondary  anaemia.  With 
each  recurrent  attack  a  fresh  local  peritonitis  is  set  up, 
which  results  in  a  matting  together  of  the  tubes,  ovaries, 
omentum,  bladder,  and  rectum.  The  distended  tube  forms  a 
rounded  tumor  that  lies  behind  or  to  the  side  of  the  uterus, 
to  which  it  is  connected  by  a  cord-like  strand  of  lead-pencil 
thickness,  and  which  in  the  absence  of  adhesions  is  movable. 


350     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

With  hydrosalpinx  the  tube  is  tense  and  not  very  tender;  it 
is  not  Hkely  to  be  adherent.  With  hematosalpinx  the  tube 
is  tense  and  tender  and  not  usually  adherent.  With  pyosal- 
pinx  the  tube  is  thickened,  sausage-shaped,  doughy,  and 
adherent. 

The  contents  of  the  tube  are  determined  from  the  patient's 
temperature,  the  leukocyte  count  (above  15,000  or  20,000 
indicating  a  pyosalpinx),  and  from  the  shape  and  thickness 
of  the  tube  walls. 

A  pyosalpinx  may  perforate  through  the  abdominal  wall, 
or  into  the  uterus  or  vagina,  or  into  the  bladder  or  rectum, 
or  into  the  peritoneal  cavity.  Perforation  into  the  perito- 
neal cavity  is  followed  by  peritonitis,  and  perforation  into 
the  bladder,  rectum,  uterus,  or  vagina  is  followed  by  a  dis- 
charge of  pus  with  the  urine  or  feces,  or  through  the  vagina. 
A  periodical  discharge  of  pus  accompanied  by  a  relief  of 
pain  and  by  a  coincident  diminution  in  the  size  of  the 
tumor  points  to  a  valve-like  orifice  of  the  perforation,  with 
periodical  retention  and  discharge  of  the  contents  of  the 
tube. 

Ovarian  cystic  tumors  are  with  difficulty  distinguishable 
from  tubal  enlargements.  Bilaterality  of  the  tumor,  sausage- 
shape,  and  a  history  of  infection  (puerperal,  gonorrhoeal,  or 
tuberculous)  speak  for  tubal  disease.  Ovarian  tumors  are 
more  movable. 

Soft  uterine  myomata  are  usually  multiple;  they  are  also 
harder,  rounder,  and  more  movable  than  tubal  tumors.  The 
history  of  infection  is  absent. 

It  is  often  impossible  to  differentiate  appendicular  exudates 
or  abscesses  occupying  the  right  side  of  the  true  pelvis  from 
tubal  abscesses.  The  history  of  previous  attacks  of  appen- 
dicitis, the  more  acute  onset  of  the  latter  illness,  the  facts 
that  with  appendicitis  the  abscess  occupies  a  higher  site,  and 
that  part  of  the  abscess  is  in  the  right  iliac  fossa,  that  the 
broad  ligament  is  not  apt  to  be  involved,  and  that  the  uterus 
is  freely  movable,  and  that  with  tubal  diseases  both  sides 
are  likely  to  be  affected,  will  aid  us  in  making  the  differential 
diagnosis.  It  is  to  be  remembered  that  with  an  appendicitis 
the  tube  may  form  one  of  the  walls  of  the  abscess  cavity,  and 
that  with  salpingitis  the  appendix  may  become  adherent  to 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     351 

the  tube.  It  is  not  unusual  for  both  organs  to  be  coincidently 
diseased. 

In  pelvic  peritonitis  the  tubes  and  ovaries  are,  as  a  rule, 
coincidently  diseased,  and  can  with  difficulty  be  separated 
from  the  inflamed  tissues. 

In  pelvic  cellulitis  and  intraligamentous  exudates  the 
vaginal  vault  is  depressed  and  the  exudate  can  be  traced  in 
front  of  and  behind  the  cervix  to  the  opposite  side.  Fre- 
quently the  appendages  are  involved  in  the  inflammation,  and 
as  the  exudate  disappears,  the  tubes  can  be  easily  recognized. 
In  pelvic  abscess  it  is  impossible  to  distinguish  the  appen- 
dages. 

Ovarian  abscesses  or  inflammation  or  cysts  of  the  ovary 
can  rarely  be  accurately  differentiated  from  tubal  disease. 
As  a  rule,  the  tube  is  diseased  coincidently  with  the  ovary. 


EXTRAUTERINE  PREGNANCY. 

Pregnancy  may  occur  in  any  part  of  the  Fallopian  tube, 
most  frequently  in  the  body  of  the  tube,  rarely  at  the  fim- 
briated end,  or  in  the  intrauterine  segment.  After  the 
impregnated  ovum  has  become  lodged  in  the  tube,  the  fim- 
briated end  becomes  closed  by  adhesions  and  the  ovum 
thus  lies  in  a  closed  sac. 

With  the  exception  of  amenorrhoea,  the  early  signs  of 
pregnancy — viz.,  morning  nausea,  vomiting,  swelling  of  the 
breasts,  pigmentation  of  the  skin,  etc. — are  present  in  cases 
of  tubal  gestation.  Instead  of  amenorrhoea  there  is  an 
irregularity  of  menstruation,  the  woman  going  several  days 
or  weeks  beyond  her  time  and  then  commencing  to  bleed 
irregularly. 

If  the  woman  does  not  know  or  suspect  that  she  is  pregnant, 
this  irregular  bleeding  may  not  give  her  much  concern;  but 
if  she  believes  herself  pregnant,  the  bleeding,  especially  if  it 
is  profuse,  together  with  the  discharge  of  membrane  with  the 
blood,  may  cause  her  to  think  that  she  has  aborted.  If  she 
seeks  medical  advice  at  this  time,  there  is  found  on  exami- 
nation either  a  solitary  hard  mass  (a  tubal  mole),  or  a  soft, 
doughy,  usually  tender,  not  adherent  mass  corresponding  to 


352     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

the  tube.  The  uterus  is  enlarged,  but  not  to  a  degree  to 
correspond  with  the  supposed  term  of  pregnancy.  If  the 
membrane  has  been  preserved  it  will  be  seen  to  be  a  decidual 
membrane.  In  many  instances  the  patient  will  have  experi- 
enced crampy,  colicky  pains  in  the  pelvis. 

If  the  diagnosis  is  not  made  in  this  stage  and  the  tubal 
pregnancy  continues  to  progress,  the  patient  will  very 
shortly  have  attacks  of  severe,  colicky  pains  in  the  lower 
abdominal  and  pelvic  regions,  in  some  of  which  she  may 
feel  faint;  and,  finally,  comes  a  severe  attack  of  pain,  ac- 
companied with  collapse  and  the  evidences  of  internal 
hemorrhage,  due  to  rupture  of  the  tube.  If  the  rupture  is 
intraperitoneal  and  occurs  during  the  early  months  of  the 
pregnancy,  there  will  be  the  physical  signs  of  free  fluid  in 
the  pelvis  and  flanks;  sometimes  the  above-described  soft, 
doughy,  tender  tumor  of  the  tube  is  to  be  felt,  and  some- 
times no  mass  whatever  can  be  palpated.  If  the  rupture  is 
extraperitoneal,  or  if  the  intraperitoneal  hemorrhage  ceases 
and  the  blood  becomes  encapsulated,  there  will  be  a  soft, 
boggy,  tender,  immovable  mass  with  indefinite  outlines  either 
between  the  layers  of  the  broad  ligament  or  behind  or  to 
the  side  of  the  uterus,  which  pushes  the  latter  to  one  side 
and  depresses  the  vaginal  vault.  The  temperature  may  be 
slightly  elevated.  The  mass  becomes  gradually  harder; 
should  it  become  infected,  there  would  be  chills,  fever,  and 
septic  symptoms.  Large  swellings  may  fill  the  entire  pelvis, 
pushing  the  uterus  to  one  side  or  backward. 

If  the  fetus  remains  alive  after  the  rupture  of  the  tube, 
heart  sounds  will  be  heard  after  the  seventh  month,  and  fetal 
movements  will  be  felt  after  the  sixteenth  to  the  eighteenth 
week.  A  continued  growth  of  the  fetus  causes  peritoneal 
irritation  with  abdominal  pain,  tenderness,  vomiting,  and 
distention;  the  foetus  occupies  an  abnormal  position  in  the 
abdomen  and  compresses  the  neighboring  viscera. 

Death  of  the  foetus  gives  the  same  symptoms  as  fetal  death 
in  uterine  pregnancies — viz.,  receding  of  the  abdomen  and 
breasts,  chills,  fever,  foul  discharge  from  the  uterus,  and 
general  physical  deterioration.  Infection  of  the  dead  foetus 
leads  to  abscess  formation  and  peritonitis. 

Perforation  of  the  abscess  into  a  hollow  viscus  is  preceded 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     353 

by  symptoms  indicating  irritation  of  this  viscus,  and  is 
followed  by  a  discharge  of  fetal  parts,  pus,  etc.,  through 
the  channels  of  exit  of  these  viscera. 

Unruptured. — An  unrwpiured  iubal  pregnancy  is  to  be 
distinguished  from  tubal  enlargements  due  to  other  causes, 
from  uterine  fibroids  and  small  ovarian  cysts. 

Irregularity  in  menstruation  is  present  in  both  salpingitis 
and  tubal  pregnancy,  but  in  the  former  there  is  a  history  and 
evidence  of  previous  genital  infection.  A  pyosalpinx  is  more 
tender,  except  in  the  chronic  stage,  and  then  it  is  considerably 
harder  and  more  adherent,  and  is  apt  to  be  prolapsed  into 
Douglas'  space.  A  tubal  mole  is  quite  hard,  but  it  is  painless, 
not  tender,  and  non-adherent.  Bilaterality  of  the  affection 
speaks  for  salpingitis,  although  it  must  be  remembered  that 
tubal  pregnancy  most  frequently  occurs  in  a  tube  that  has 
been  the  seat  of  previous  disease.  A  careful  anamnesis  is 
of  considerable  value  in  making  the  diagnosis. 

Uterine  fibroids  are  usually  multiple,  more  irregular  and 
hard.  They  have  an  entirely  different  history  (see  p.  345) 
and  can  be  traced  to  the  body  of  the  uterus.  There  are  no 
evidences  of  pregnancy. 

Ovarian  cysts  have  a  pedicle,  and  are  not  attended  with 
the  signs  of  early  pregnancy;  they  are  usually  fluctuating 
and  tense,  and  have  a  smooth  surface. 

Ruptured. — A  ruptured  tubal  pregnancy  may  be  mistaken 
for  acute  perforative  appendicitis  or  twisted  ovarian  cyst. 

In  acute  appendicitis  there  is  rarely  the  profound  collapse 
or  the  evidences  of  internal  hemorrhage.  Appendicular 
exudates  are  wholly  or  in  part  higher  up  than  are  tubal 
pregnancies.  The  tube  is  felt  to  be  normal.  There  are  no 
evidences  of  pregnancy. 

An  ovarian  cyst  whose  pedicle  has  become  twisted  is 
attended  with  crampy,  colicky,  pelvic  pain  that  may  suggest 
tubal  rupture;  but  such  a  cyst  and  its  pedicle  are  to  be 
readily  palpated,  the  accident  is  not  attended  with  collapse, 
and  there  are  no  signs  of  early  pregnancy. 

Pregnancy  in  a  bieornate  uterus  is  distinguished  from  tubal 
pregnancy  by  the  lopsided  shape  of  the  uterus  (owing  to 
the  unimpregnated  horn),  and  by  the  low,  broad  connec- 
tion of  the  sac  with  the  cervical  end  of  the  uterus. 

23 


CHAPTER   XXXIII. 

DISEASES  OF  THE  FEMALE  PELVIC  ORGANS 

(Continued). 

INFLAMMATION  OF  THE  OVARIES. 

Women  may  suffer  considerable  pelvic  weight  and  pain 
which  radiates  down  into  the  thighs,  from  a  chronic  follicular 
oophoritis.  The  ovaries  in  these  cases  feel  swollen,  soft,  and 
very  tender.  Hemorrhage  into  or  suppuration  of  the  small 
cysts,  which  go  with  this  condition  of  the  organ,  causes 
increased  pain  and  swelling,  with  moderate  temperature 
elevations.  Occasionally  one  of  these  cysts  grows  to  the 
size  of  a  child's  head;  it  is  tense  and  has  thin  walls,  and  can 
only  be  differentiated  from  neoplastic  cysts  of  the  organ  by 
laparotomy. 

NEOPLASMS  OF  OVARY. 

Among  the  chief  varieties  of  ovarian  new-growths  are: 

Multiple  cystic  adenoma,  with  serous  or  pseudomucinous 
contents. 

Papillary  cystic  adenoma,  with  pseudomucinous  contents. 

Solid  papillary  tumors. 
\    Papillary  adenocarcinoma  and  sarcoma. 

Carcinoma,  sarcoma,  fibroma,  dermoids,  and  parovarian 
cysts. 

Ovarian  tumors  are  attached  to  the  broad  ligament  by  a 
pedicle,  in  which  the  meso-ovarian  and  the  utero-ovarian 
ligaments,  the  mesosalpinx,  the  uterine  tube,  and  the  broad 
ligament  enter.  The  relations  of  these  structures  vary 
greatly,  according  as  the  tumor  grows  upward  into  the 
abdominal  cavity  or  downward  toward  the  pelvic  floor. 
Thus  the  meso-ovarian  and  the  utero-ovarian  ligaments  may 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     355 

be  stretched  out  into  a  long  pedicle;  again,  the  tumor  may 
develop  in  the  outer  part  of  the  mesosalpinx,  and  the  ampullar 
end  of  the  tube  be  spread  out  over  the  surface.  The  whole 
mesosalpinx  may  be  spread  apart,  and  the  tube  stretched 
out  on  its  surface.  Continued  development  of  the  latter 
tumors  opens  up  the  lower  part  of  the  broad  ligament,  and 
raises  the  pelvic  and  abdominal  peritoneum  (thus  forming 
the  broad-ligament  tumors).  The  pseudointraligamentous  or, 
better  termed,  the  retroligamentous  tumors  attain  this  position 
from  having  fallen  backward  into  the  pelvis  behind  the  broad 
ligament,  to  the  posterior  layer  of  which  they  become  adhe- 
rent.   The  mesosalpinx  covers  over  these  tumors  as  a  hood. 

As  long  as  ovarian  tumors  are  small  and  do  not  distend 
the  abdominal  wall  or  cause  pressure  upon  the  abdominal 
viscera,  or  suffer  any  complications,  they  will  not  attract 
attention,  for  their  mere  presence  does  not,  as  a  rule,  cause 
any  symptoms.  Not  even  menstrual  irregularities  are  pro- 
voked by  them,  to  disturb  the  usual  equanimity  of  the 
patient,  or  to  warn  her  that  something  is  wrong  with  her 
pelvic  organs.  The  woman's  first  complaints  are  usually 
from  pressure  of  the  tumor  upon  the  pelvic  and  abdominal 
organs,  pressure  being  indicated  by  irritability  of  the  affected 
viscus  or  by  stenosis  of  its  lumen,  or  by  pain.  The  last  is 
especially  marked  if  the  nerves  are  compressed.  The  pain 
is  pelvic;  it  may  radiate  to  the  small  of  the  back  or  down 
the  thigh.  Distention  of  the  abdomen  occurs  only  with 
large  tumors,  unless  it  be  due  to  ascites,  which  is  an  early 
symptom  of  all  malignant  and  papillary  growths. 

It  frequently  happens  that  the  cyst  causes  no  disturbances 
and  consequently  escapes  detection  until  a  complication 
arises.  Such  complications  are  twisting  of  its  pedicle, 
rupture  of  its  walls,  incarceration,  inflammation  and  suppu- 
ration, and  malignant  degeneration. 

Twist  of  the  pedicle  is  attended  by  crampy  pelvic  and 
abdominal  pains,  vomiting,  shock,  and  peritoneal  irritations. 
If  the  twist  is  sufficient  to  cause  strangulation  of  the  pedicle, 
gangrene  of  the  cyst  with  subsequent  peritonitis  will  result. 
If  the  presence  of  the  cyst  and  its  size  were  known  before 
the  twist  of  its  pedicle  occurred,  an  increase  in  its  dimensions 
will  be  observed  to  follow  this  condition. 


356     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

Rupture  of  the  cyst  may  be  followed  by  death  from  internal 
hemorrhage  if  a  large  vessel  is  torn.  This  is,  however,  a  rare 
occurrence.  If  the  cyst  contents  are  bland,  there  follows 
diarrhoea  or  polyuria;  if  they  are  irritating,  peritonitis  with 
the  formation  of  adhesions  ensues.  Rupture  of  papillary 
cysts  has  an  especial  significance,  for  dissemination  of  the 
growth  over  the  peritoneum  follows  upon  it.  If  the  presence 
of  the  cyst  was  known  prior  to  its  rupture,  this  complication 
would  be  observed  to  cause  a  decrease  in  its  size  or  even  its 
entire  disappearance. 

Incarceration  of  the  cyst  in  the  pelvis  is  manifested  by 
pelvic  pain  and  the  signs  of  peritoneal  irritation.  Gangrene 
of  the  cyst  is  followed  by  septic  peritonitis,  but  this  rarely 
occurs  from  this  accident. 

Suppuration  of  the  cyst  is  a  rare  occurrence;  it  is  indicated 
by  fever,  emaciation,  and  increase  in  the  size  of  the  tumor. 


DIAGNOSIS  OF  THE  PRESENCE  OF  A  TUMOR. 

It  is  a  good  rule  never  to  diagnosticate  the  presence  of  an 
ovarian  cyst  unless  it  can  be  palpated.  This  is  not  always 
easy;  and  especially  is  it  difficult  where  the  woman  is  fat, 
and  the  cyst  is  small  and  flaccid.  If  palpation  is  rendered 
difficult  by  rigid  abdominal  walls,  an  anaesthetic  should  be 
administered. 

Ovarian  tumors  have  the  following  characteristics :  Those 
that  extend  up  into  the  abdomen  are  dull  to  percussion  over 
their  convexity  and  below  toward  the  pelvis,  and  are  sur- 
rounded above  and  at  the  sides  by  a  zone  of  tympanitic 
resonance.  They  are  attached  to  the  broad  ligament  by  a 
pedicle,  which  can  often  be  palpated  per  rectum,  and  they 
replace  the  ovary  of  the  side  from  which  they  spring. 

The  distention  of  the  abdomen  due  to  intestinal  disten- 
tion, to  bladder  distention,  and  to  tuberculous  and  chronic 
exudative  peritonitis,  is  readily  distinguished  from  that  due 
to  an  ovarian  tumor.  With  intestinal  distention  the  abdomen 
is  everywhere  tympanitic.  An  overdistended  bladder  has  an 
elongated,  ovoid  shape,  a  symmetrical  form,  lies  in  the 
median  line,  and  disappears  when  the  bladder  is  emptied 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     357 

by  a  catheter,  a  procedure,  by  the  way,  that  should  always 
be  carried  out  before  an  examination  is  made.  Tuberculous 
and  other  chronic  forms  of  peritonitis  with  exudation  are 
characterized  by  irregular  areas  of  tympany  and  dulness, 
which  alter  their  position  and  their  size  from  time  to  time. 
The  sacculations  of  fluid  have  indefinite  outlines,  and  slight 
mobility. 

Small  ovarian  tumors  must  be  differentiated  from  uterine 
tumors,  tubal  enlargements,  pelvic  exudates,  and  fecal  masses. 
Ovarian  tumors  lie  to  one  side  of  or  behind  the  uterus,  are 
usually  smooth  and  round,  cystic  and  fluctuant,  enjoy  inde- 
pendent mobility,  and  are  connected  to  the  uterus  by  the 
corresponding  utero-ovarian  ligament.  Myomata  are  usually 
multiple,  grow  more  slowly,  and  are  harder.  Their  attach- 
ment to  the  uterus  is  not  by  the  utero-ovarian  ligament. 
They  distort  and  elongate  the  uterine  canal.  Menstruation 
is  usually  profuse  and  painful.  Tubal  tumors  are  sausage- 
shaped;  they  follow  a  preceding  vaginal  and  uterine  infection; 
they  are  usually  adherent  in  Douglas'  sac,  and  their  narrow, 
pipe-stem  pedicle,  which  can,  as  a  rule,  be  palpated,  corre- 
sponds to  the  uterine  end  of  the  tube.  Pelvic  exudates  follow 
a  genital  infection.  The  swelling  they  occasion  is  diffuse, 
not  mobile,  and  is  attached  to  the  uterus  and  iliac  wall;  the 
uterus  is  fixed  and  very  painful  when  attempts  are  made  to 
move  it.  They  are  attended  with  fever  and  constitutional 
disturbances. 

An  extraperitoneal  hoBmatoma  is  diffuse  and  non-mobile. 
At  first  it  is  soft  and  boggy;  later  on  it  becomes  hard  and 
tender.  Both  hemorrhage  and  exudates  tend  to  become 
smaller;  cysts  larger. 

Fecal  masses  differ  from  ovarian  cysts  in  that  they  dis- 
appear when  the  bowels  are  thoroughly  purged. 

Medium-sized  ovarian  tumors  are  oval,  smooth,  and  have 
at  times  a  knobbed  surface.  They  are  easily  palpated.  By 
grasping  the  cervix  with  a  bullet-forceps  and  dragging  it 
downward,  and  at  the  same  time  pulling  the  tumor  upward 
into  the  abdomen,  the  pedicle  is  put  on  the  stretch  and  can 
be  then  easily  palpated  through  the  rectum  or  vagina.  The 
uterus  can  also  by  this  procedure  be  more  easily  and  definitely 
palpated;  it  is  felt  to  be  distinct  from  the  tumor,  which  latter 


358     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

nevertheless  participates  in  the  downward  movement  that  is 
imparted  to  the  uterus  by  the  traction  on  the  cervix. 

Medium-sized  tumors  are  to  be  differentiated  from  preg- 
nancy in  the  fourth  to  the  sixth  months,  from  tumors  of  other 
abdominal  organs,  from  tumors  of  the  abdominal  wall,  from 
other  pelvic  tumors,  and  from  ascites.  In  pregnancy  the 
tumor  which  is  formed  by  the  body  of  the  uterus  is  directly 
continuous  with  the  cervix  uteri.  This  characteristic  of  the 
tumor,  together  with  the  other  signs  of  pregnancy,  of  which 
ballottement  is  especially  important,  readily  enables  us  to 
make  the  differentiation.  In  the  fifth  and  sixth  months  of 
pregnancy  the  fetal  heart  sounds,  the  palpation  of  fetal  parts, 

Fig"  144. 


Shape  of  abdomen  in  ovarian  or  uterine  tumor.  Compare  with  Fig.  125,  showing 
distention  of  abdomen  with  ascitic  fluid.  Note  absence  of  protruding  umbilicus 
and  flatness  of  the  flanks. 


and  the  uterine  bruits  leave  no  room  for  mistake  in  diagnosis. 
With  hydramnios  or  death  of  the  fetus,  the  signs  of  pregnancy, 
and  the  fact  that  the  tumor  is  directly  continuous  with  the 
cervix  will  enable  the  examiner  to  rule  out  an  ovarian  cyst. 
Tumors  of  other  abdominal  organs,  stomach,  intestines, 
kidney,  spleen,  omentum,  etc.,  all  fall  away  from  the  pelvis 
and  toward  the  diaphragm  when  the  patient  is  put  into 
Trendelenburg's  position,  thus  showing  that  they  have  no 
pelvic  connection.  When  such  tumors  are  adherent,  the 
pelvic  organs  must  be  carefully  mapped  out  per  vaginam, 
and  their  relations  to  the  tumor  determined. 


DISEASES  OF   THE  FEMALE  PELVIC  ORGANS     359 

Tumors  of  and  exudates  in  the  abdominal  wall  are  usually 
harder  than  ovarian  cysts.  They  move  with  the  abdominal 
wall  in  respiration — i.  e.,  with  the  patient  in  the  dorsal  recum- 
bent position  they  move  forward  and  backward.  Their  shape 
is  flattened,  and  they  have  no  relation  to  the  pelvic  organs. 

Free  ascites  gives  to  the  abdomen  a  barrel-shape  when  the 
patient  is  in  the  dorsal  recumbent  position;  the  flanks  bulge, 
have  a  dull  note  on  superficial  percussion,  and  a  dull  tympan- 
itic note  on  deep  percussion,  and  the  centre  of  the  abdomen 
is  tympanitic.  With  change  in  the  patient's  position  to  one 
side  the  upper  flank  becomes  tympanitic  to  percussion.  With 
tumor  the  percussion  note  over  the  tumor  is  always  dull. 

Echinococcus  cysts  of  the  pelvis  are  usually  adherent;  they 
are  of  slow  growth,  and  are  apt  to  be  associated  with  echino- 
coccic  disease  of  other  organs.  The  normal  condition  of  the 
uterus  and  ovaries  shows  that  these  organs  are  not  involved 
in  the  cystic  degeneration. 

Very  large  ovarian  tumors  are  more  difficult  of  differ- 
entiation because  they  occupy  the  entire  abdominal  and 
pelvic  cavities.  They  have  no  mobility  from  lack  of  space, 
and  their  pedicles  are  difficult  to  make  out.  Tympanitic 
resonance  over  the  abdomen  is  only  present  well  back  in  the 
ffanks,  and  high  up  under  the  ribs;  in  all  other  parts  the 
percussion  note  is  dull.  The  uterus  is  displaced;  either  it  is 
crowded  down  into  the  pelvic  floor  or  elevated  out  of  the 
pelvis  in  front  of  the  tumor,  where  it  can  often  be  felt  above 
the  symphysis.    The  entire  pelvis  is  filled  with  the  tumor. 

The  differential  diagnosis  must  be  made  from  free  ascites. 
(See  above  and  p.  252.) 

Ascites  complicating  tumor:  The  tumor  can  at  times  be 
felt  per  vaginam,  while  the  ascites  gives  the  usual  symptoms. 

DIAGNOSIS  OF  THE  NATURE  OF  THE  TUMOR. 

As  a  rule  the  cystic  tumors  can  be  differentiated  from  the 
solid  ones  by  their  markedly  different  resistance,  their  larger 
size,  and  their  more  frequent  association  with  ascites.  Among 
the  cystic  tumors  must  be  distinguished  the  multilocular 
cysts,  cystic  papilloma,  dermoids,  parovarian  cysts,  cystic 
sarcoma,  and  carcinoma. 


360     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

A  muUilocular  cyst  is  irregular  in  contour,  the  irregularity 
corresponding  to  the  depressions  between  the  cysts.  The 
wall  feels  thick,  and  as  its  contents  are  viscid  the  sensation 
of  fluctuation  is  indistinct.  Irregular  bosses  of  varying 
tenseness  may  be  made  out.  Cystic  pa'pillomata  that  have 
a  smooth  cyst  wall  cannot  be  distinguished  from  other  cystic 
tumors.  If  the  papillomata  form  excrescences  on  the  surface 
of  the  cyst,  these  may  be  felt  through  the  vagina.  The 
presence  of  ascites  with  a  small,  fixed  pelvic  tumor  and 
with  no  cachexia  should  arouse  our  suspicion  of  such  growths. 
Extensive  metastatic,  papillary  excrescences  in  the  abdomen 
are  easily  palpable  when  the  coexistent  ascitic  fluid  is 
removed. 

Dermoids  are  usually  monocystic,  single,  and  not  much 
larger  than  an  adult  head.  They  are  of  soft,  mushy  con- 
sistency, of  slow  growth,  float  up  in  front  of  the  uterus, 
occur  chiefly  in  children  and  in  young  women,  and  are 
frequently  tender. 

Parovarian  cysts  are  unilocular.  They  usually  have  thin 
walls  and  a  broad  base  of  origin,  and  are  intraligamentous. 
They  may  have  an  irregular  contour,  and  resemble  multi- 
locular  cysts.    They  occur  chiefly  in  young  subjects. 

Cystic  sarcomata  and  carcinomata  are  unilocular;  they 
have  thick  walls.  When  they  reach  large  size  they  occasion 
ascites,  cachexia,  emaciation,  and  metastases.  When  they 
are  small  they  have  no  especial  characteristics. 

Among  the  hard  tumors  are  the  fibroma  and  solid  sarcoma 
and  carcinoma.  The  fibroma  is  a  hard  tumor,  not  very  large, 
is  accompanied  by  ascites,  but  not  with  cachexia,  emaciation, 
or  metastases.  Carcinoma  and  sarcoma  are  larger,  and  may 
involve  both  ovaries.  The  latter  occur  in  young  subjects, 
are  often  secondary  to  sarcoma  of  the  stomach,  and  are 
attended  with  ascites,  cachexia,  emaciation,  and  metastases. 

Malignant  degeneration  of  a  benign  tianor  is  indicated  by 
its  rapid  enlargement,  by  pain,  ascites,  cachexia  and  oedema 
of  the  legs  and  abdominal  walls. 

Adhesions  between  the  cyst  and  neighboring  viscera  are 
indicated  by  a  loss  of  its  mobility,  an  increase  of  its  tender- 
ness, and  by  the  presence  of  peritoneal  friction  sounds. 


CHAPTER    XXXIV. 
DISEASES  OF  THE  RECTUM. 

METHOD  OF  EXAMINATION  OF  THE  ANUS  AND  RECTUM. 

The  symptoms  which  are  occasioned  by  diseased  con- 
ditions of  the  rectum  are  constipation  or  diarrhoea,  tenesmus, 
pain,  itching,  discomfort  or  uneasiness  about  the  anus,  pro- 
lapse or  protrusion  about  the  anus,  bleeding  from  the  rectum, 
and  a  discharge  of  mucus  or  pus  or  blood  with  the  stools. 

It  is  unfortunately  too  common  for  physicians  to  make 
their  diagnoses  of  rectal  disorders  from  these  symptoms, 
without  the  aid  of  the  essential  data  that  are  afforded  by  a 
local  examination.  This  explains  why  their  diagnoses  are 
so  often  wrong,  and  further  accounts  for  their  frequent 
inability  to  effect  a  cure  of  the  malady.  The  first  requisite 
for  a  successful  issue  of  our  therapy  in  diseases  of  this  organ 
is  an  accurate  diagnosis  not  only  of  the  local  disorder,  but 
of  the  cause  therefor,  and  this  can  only  be  made  by  a  thorough 
examination  of  the  rectum  and  of  the  other  abdominal  and 
thoracic  organs. 

The  local  examination  should  be  made  soon  after  the 
rectum  has  been  evacuated,  though  where  there  is  a  discharge 
of  blood,  or  pus  or  mucus,  it  may  be  advisable  to  make  a 
re-examination  several  hours  after  defecation.  In  such  cases 
it  is  best  to  make  the  examinations  on  two  successive  days. 
The  patient  for  examination  should  be  laid  upon  a  couch 
or  table  in  the  left  lateral  (Sims')  position,  in  the  exagger- 
ated lithotomy  position,  in  the  knee-chest  position,  or,  when 
protrusion  or  prolapse  is  suspected,  in  the  squatting  position. 

Our  attention  should  first  be  directed  to  the  external  anal 
appearances ;  its  shape,  the  condition  of  the  surrounding  skin ; 
whether  it  is  moist,  or  dry,  or  brittle,  or  red,  or  excoriated; 
whether  parasites   or  pediculi  are  lodged  in  the  external 


362     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

hairs,  and  whether  there  are  present  protrusions,  or  scars,  or 
ulcerations,  or  fistulous  openings,  or  external  growths,  such 
as  condylomata,  fibroids,  polypi  or  skin-tabs.  The  but- 
tocks should  then  be  pulled  well  apart  and,  while  the 
patient  strains  slightly,  we  should  inspect  the  anal  canal, 
noting  the  mucocutaneous  border;  whether  it  is  soft  and 
moist,  or  dry,  brittle,  crackling,  and  bleeding,  as  in  atrophic 
rectal  catarrh  and  syphilis.  The  condition  of  the  anal  folds, 
whether  they  are  normal  or  inflamed  and  swollen,  and  the 
presence  of  fissures,  hemorrhoids,  polypi,  or  new-growths, 
are  likewise  to  be  taken  note  of. 

The  finger,  covered  with  a  rubber  finger-stall  and  well 
lubricated,  should  now  be  slowly  introduced  with  a  boring 
motion,  at  first  upward  and  forward  and  then  backward, 
feeling  as  it  enters  the  tonicity  and  irritability  of  the  sphincter 
muscle.  Irritability  points  to  acute  disease;  a  hard,  resisting 
sphincter  indicates  hypertrophy  from  chronic  disease,  and  a 
relaxed,  fiaccid  muscle  speaks  for  an  exhausting  general 
disease  or  neoplasm  of  the  rectum.  As  the  finger  passes  into 
the  bowel  the  presence  of  ulcers,  of  abnormal  openings,  of 
abscesses,  of  hypertrophied,  inflamed  or  thrombosed  hemor- 
rhoids, of  foreign  bodies,  of  neoplasms  or  of  strictures,  should 
be  noted,  and  likewise  the  position,  mobility,  and  config- 
uration of  the  generative  organs,  of  the  bladder,  of  the 
prostate,  and  of  the  coccyx.  The  presence  of  pelvic  tumors 
should  also  be  ascertained.  As  the  finger  is  withdrawn  the 
patient  should  be  asked  to  bear  down,  so  that  if  prolapse 
or  hemorrhoids  or  pus  or  blood  are  present,  they  should 
follow  it  out  through  the  anus. 

Inspection  of  the  rectum  through  the  proctoscope  is  often 
necessary  to  differentiate  the  digital  findings,  and  for  the 
examination  of  the  upper  rectum  and  sigmoid  flexure  the 
proctoscope  and  sigmoidoscope  should  be  employed. 

When  we  have  thus  ascertained  the  nature  of  the  rectal 
malady,  we  should  direct  our  attention  to  the  internal  organs 
and  to  the  anamnesis  for  a  possible  explanation  of  the  local 
condition.  The  diseases  of  the  liver  are  especially  likely  to 
be  the  cause  of  rectal  disorders,  and  conversely  diseases  of 
the  rectum  frequently  give  rise  to  secondary  lesions  in  the 
liver.     The  careful  percussion  and  palpation  of  this  organ 


DISEASES  OF   THE   RECTUM  363 

should  therefore  never  be  neglected  when  the  rectum  is 
diseased.  The  antecedent  family  and  personal  history,  espe- 
cially as  to  gonorrhoea,  syphilis,  and  tuberculosis,  should 
also  be  elicited,  and  their  bearing  upon  the  diseased  condition 
given  due  consideration.  The  previous  and  present  health 
and  weight  of  the  patient,  and  the  presence  of  symptoms 
referable  to  the  genitourinary  organs  are  often  valuable 
guides  toward  indicating  the  extent  and  character  of  the 
rectal  malady. 


THE  SPECIAL  DISEASES  OF  THE  RECTUM. 

Atresia  of  the  Anus  and  Rectum.— It  should  be  the 
practice  of  obstetricians  and  nurses  to  inspect  and  deter- 
mine the  patency  of  the  anal  and  urethral  orifices  of  the 
newly  born  babe,  for  among  the  ignorant  a  congenital 
defect  or  malformation  that  is  not  detected  and  announced 
at  the  time  of  birth  is  often  ascribed  to  the  carelessness  or 
incompetency  of  the  physician  in  charge.  Such  examina- 
tion will  at  times  reveal  that  there  is  no  anal  orifice,  but 
while  the  child  cries  a  bulging  may  be  noticed  in  the  peri- 
neum; the  condition  is  one  of  atresia  ani.  Or  the  anus 
is  absent  and  no  bulging  in  the  perineum  is  to  be  seen;  the 
condition  is  one  of  atresia  ani  et  recti.  Sometimes  the  anus 
is  present,  but  it  leads  into  a  blind  cul-de-sac;  the  condition 
is  one  of  atresia  recti.  In  all  these  cases  there  will  develop 
the  symptoms  of  intestinal  obstruction,  unless  an  opening 
for  the  evacuation  of  the  contents  of  the  bowel  is  speedily 
made.  Abnormal  congenital  openings  between  the  rectum  and 
bladder,  urethra,  vagina,  or  external  genital  organs  are  readily 
recognized  by  the  discharge  of  fecal  matter  through  these 
abnormal  channels.  Such  conditions  are  rare  and  are  usually 
associated  with  imperforate  conditions  of  the  anus. 

Prolapse. — A  conical  protrusion  of  the  mucous  membrane 
or  of  the  entire  wall  of  the  rectum  is  seen  quite  often  in 
childhood,  less  frequently  in  adult  and  advanced  life.  The 
protrusion  is  attended  with  bleeding  and  some  pain,  and  is 
first  noticed  by  the  mother  or  patient  at  the  end  of  defeca- 
tion.    The  protruded  part  may  be  a  simple  prolapse  of  the 


364     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

end  of  the  rectum,  or  it  may  be  a  higher  portion  of  the 
rectum  that  has  invaginated  itself  through  the  anus.  In 
the  former  instance  the  mucous  membrane  covering  the  pro- 
truded part  is  directly  continuous  with  the  mucocutaneous 
border,  and  the  finger  cannot  be  introduced  into  the  anus 
alongside  of  it,  whereas  in  the  latter  the  finger  can  be  passed 
into  the  anus  alongside  of  the  protrusion,  and  can  be  swept 
entirely  around  it.  A  protruding  invagination  of  the  rectum 
through  the  anus  is  differentiated  from  a  protruding  intussus- 
ceptum  of  a  higher  portion  of  the  bowel  by  the  fact  that  in 
the  latter  condition  the  finger,  when  introduced  into  the 
rectum  alongside  of  the  protrusion,  meets  with  no  ob- 
struction to  its  passage  upward,  while  in  the  former  an 
obstruction  is  encountered  a  short  distance  from  the  anal 
aperture. 

Prolapsing  hemorrhoids  are  distinguished  from  simple 
prolapse  by  their  irregular,  lobulated  shape,  the  varicose  con- 
dition of  the  vessels,  and  by  the  fact  that  at  certain  portions 
of  the  circumference  of  the  rectum  the  mucous  membrane 
remains  in  situ. 

When  the  prolapsed  mucous  membrane  becomes  excoriated, 
hypertrophic,  and  nodular,  it  bears  a  strong  resemblance  to 
a  neoplasm,  and  can  only  be  distinguished  from  it  by 
microscopic  examination  of  an  excised  specimen. 

Hemorrhoids. — A  varicose  condition  of  the  hemorrhoidal 
veins  {hemorrhoids)  is  very  readily  recognized.  When  the 
vessels  external  to  the  sphincter  ani  are  affected  {external 
hemorrhoids),  they  appear  as  single  or  multiple,  bluish,  soft 
nodes  with  a  broad  base,  that  swell  upon  straining  and  that 
are  easily  emptied  by  pressure.  When  they  become  inflamed, 
they  are  swollen,  painful,  tender  and  hard,  and  can  no  longer 
be  emptied  by  pressure;  at  such  time  they  occasion  marked 
rectal  tenesmus.  Acutely  inflamed  or  thrombosed  external 
hemorrhoids  or  a  chronic  irritation  about  the  anus  often 
result  in  the  formation  of  skin-tabs  about  the  anus,  some- 
times called  fleshy  piles.  These  cause  annoyance  only  when 
they  become  inflamed. 

The  internal  hemorrhoids  appear  as  sessile  prominences, 
sometimes  single,  and  again  multiple,  of  irregular,  lobulated 
shape;  they  occasion  bleeding,  prolapse  and  pain.     When 


DISEASES  OF   THE  RECTUM 


365 


they  are  prolapsed  or  inflamed,  they  form  globular  swell- 
ings with  glistening  surface. 

Hemorrhoids  are  always  to  be  considered  as  symptomatic 
of  some  other  disease  or  as  due  to  functional  derangement 
of  the  bowel,  and  to  the  ascertainment  of  their  underlying 


Fir.  145. 


Ulcerating  and  prolapsed  internal  hemorrhoids.    Note  the  lobulation  of  the 
protruding  masses. 

cause  we  should  in  every  case  devote  our  attention.  The 
most  frequent  causes  of  hemorrhoids  are  diseases  of  the 
heart,  lungs,  and  liver,  neoplasms  of  the  rectum,  neoplasms 
or  malposition  of  the  internal  female  genital  organs,  stricture 


366     INJURIES  AND  DISEASES  OF   THE  ABDOMEN 

of  the  urethra,  enlarged  prostate,  and  vesical  stone,  and  until 
a  thorough  examination  has  shown  an  absence  of  these  con- 
ditions we  are  not  justified  in  considering  that  they  are  due 
to  functional  disturbances  of  the  bowel. 

Inflammation  and  Ulceration. — A  discharge  of  mucus, 
blood,  and  pus  from  the  rectum,  with  tenesmus  and  reflex 
urethral  and  vesical  irritability,  is  indicative  of  inflammation 
and  ulceration  of  the  rectum.  The  previous  history  of  the 
patient,  the  evidences  of  some  constitutional  disease  in  other 
organs,  and  the  appearances  of  the  ulcerations  throw  light 
upon  the  especial  character  of  the  inflammatory  or  ulcerative 
process. 

An  acute  onset  with  some  fever,  malaise,  rectal  pain, 
rectal  and  vesical  tenesmus,  and  the  discharge  of  mucus  or 
blood  or  pus  from  the  rectum  speak  for  acute  proctitis,  the 
cause  of  which  must  be  sought  in  some  error  or  over- 
indulgence in  diet  or  drink,  in  some  constitutional  disease, 
in  gonorrhoea,  worms,  etc.  Through  the  speculum  the  mucous 
membrane  appears  of  a  bright-red  color,  at  first  dry  and 
swollen,  and  later  on  covered  with  mucus  or  blood  or  pus. 

A  gradual  onset  marked  by  flatulence,  tenesmus,  loss  of 
appetite,  alternating  constipation  and  diarrhoea,  a  discharge 
of  mucopus  sometimes  tinged  with  blood,  and  a  feeling  of 
weight  and  discomfort  in  the  rectum  are  suggestive  of  chronic 
inflammation.  Such  a  chronic  process  may  also  be  the 
remains  of  an  acute  inflammation.  If  there  is  a  marked 
tendency  to  bleeding  and  the  development  of  fissures  around 
the  anus,  if  the  mucous  membrane  is  dry  and  cracks  easily 
and  tends  to  ulcerate,  the  inflammation  is  of  the  atrophic 
variety,  a  frequent  result  of  sodomy,  improper  hygienic  con- 
ditions, or  syphilis. 

The  ulcerative  lesions  are  chiefly  of  the  tuberculous,  syphi- 
litic, gonorrhoeal,  inflammatory,  or  neoplastic  types.  They  all 
occasion  about  the  same  character  of  symptoms — viz.,  pain 
in  the  back,  diarrhoea,  tenesmus,  and  a  discharge  of  blood, 
mucus,  and  pus.  The  discharge  is  very  profuse  in  the 
syphilitic  ulcerations,  and  foul  and  decomposing  in  odor  in 
the  tuberculous  and  neoplastic. 

An  acute  onset  of  the  symptoms  in  a  patient  who  has 
recently  lived  in  the  tropics,  and  the  presence  of  narrow, 


DISEASES  OF   THE  RECTUM  367 

linear,  or  stellate  ulcerations  having  sharply  defined  borders, 
the  scrapings  from  which  contain  the  amoebse  coli,  are 
indicative  of  aincehic  'proctitis. 

A  very  slight  grade  of  symptoms  with  marked  chronicity 
occurring  in  a  patient  who  suffers  with  hemorrhoids,  and  the 
presence  of  sharply  defined,  irregular  ulcers  of  the  mucous 
membrane  between  the  hemorrhoidal  masses  speak  for 
varicose  ulcers.  These  must  be  distinguished  from  the  super- 
ficial or  teat-like  ulcers  on  top  of  the  hemorrhoidal  masses 
which  are  due  to  inflammation  of  the  latter. 

A  gradual,  insidious  onset  of  the  symptoms  in  a  tuberculous 
subject,  with  the  presence  of  irregular,  grayish  ulcers  having 
undetermined  and  worm-eaten  edges,  points  to  tuberculosis. 

A  gradual  onset  in  a  syphilitic  subject  who  presents  other 
evidences  of  syphilis  in  the  skin,  bones,  mucous  membranes, 
etc.,  together  with  crater-shaped,  sharply  defined  ulcers 
that  discharge  profusely,  speak  for  syphilis.  In  connection 
with  this  disease  it  is  well  to  remember  the  characteristic 
papillary  growths  (broad  condylomata)  and  the  mucous 
patches  that  occur  during  the  secondary  period,  and  the 
soft,  elastic,  rounded  swellings  (gummata)  that  develop 
during  the  tertiary  period,  and  also  the  initial  erythema  or 
dermatitis  with  shallow  fissures  between  the  anal  folds 
followed  by  perianal  ulcerations  with  seropurulent  discharge 
that  occurs  in  infants  as  a  result  of  hereditary  infection. 

The  presence  of  a  hard,  fixed,  rapidly  growing  tumor  in 
the  wall  of  the  rectum,  which  breaks  down  and  leaves  an 
ulcer  that  has  hard,  everted  edges  and  necrotic  base,  is 
indicative  of  a  malignant  neoplasm. 

A  gradual  onset  of  the  symptoms  in  a  patient  who  is  in 
the  terminal  stages  of  chronic  Bright's  disease,  diabetes, 
cirrhosis  of  the  liver,  or  marasmus,  points  to  ulceration  due 
to  these  constitutional  disorders.  As  these  individuals  are 
already  near  their  end,  the  rectal  ulcerations  are  of  impor- 
tance only  in  so  far  as  the  sufferings  of  the  patient  are  thereby 
considerably  increased. 

Stricture  of  Rectum. — Stricture  of  the  rectum,  which  is 
manifested  by  an  increasing  tendency  to  constipation  alter- 
nating with  diarrhoea,  tape-like  stools,  and  mucopurulent, 
bloody,  or  foul  rectal  discharge,  is  either  benign  or  malign 


368     INJURIES  AND  DISEASES  OF  THE  ABDOMEN 

in  character.  A  preceding  history  of  simple  or  syphiUtic 
ulceration  and  a  multiple  number  of  strictures  speaks  for 
their  benign  character,  while  a  hard,  fixed,  ulcerating  tumor 
in  an  elderly  person  that  occasions  a  foul  discharge  and  that 
is  attended  with  emaciation  and  cachexia  is  indicative  of  its 
malignant  nature. 

Most  of  the  cases  of  stricture  of  the  rectum,  and  especially 
those  of  the  malignant  type,  are  attended  with  hemorrhoids, 
and  it  is  the  disturbances  which  these  latter  provoke  that 
very  often  first  attract  the  patient's  attention.  This  explains 
why  so  many  of  these  cases  are  diagnosticated  as  hemor- 
rhoids, and  it  should  teach  us  never  to  rest  satisfied  with 
the  diagnosis  of  hemorrhoids  until  a  thorough  and  careful 
rectal,  pelvic,  abdominal,  and  thoracic  examination  has  shown 
that  they  are  not  dependent  upon  some  other  malady. 

Polypi. — Frequently  recurring  severe  hemorrhages  from 
the  rectum,  especially  in  children,  are  very  suggestive  of 
rectal  polypi.  The  diagnosis  is  easily  verified  by  digital 
examination. 

Periproctitis. — Pain,  tenderness,  and  rectal  tenesmus, 
together  with  the  presence  of  a  doughy  or  fluctuating  swell- 
ing in  the  perianal  or  perirectal  cellular  tissues,  are  evidences 
of  a  periproctitis,  the  cause  for  which  must  be  sought  in 
some  inflammatory  or  ulcerative  condition  or  injury  of  the 
rectum,  or  in  some  inflammatory  disease  within  the  pelvis 
or  of  its  bony  walls. 

Fistula. — Periproctitis  is  frequently  followed  by  fistulse  in 
ano  or  flstulse  in  recto.  If  these  are  complete — i.  e.,  have 
both  an  internal  and  external  opening — there  is  usually  an 
escape  of  gas  and  fecal  matter  from  the  external  orifice. 
The  internal  opening  can  sometimes  be  palpated  by  the 
finger  in  the  rectum  and  sometimes  be  seen  with  the  proc- 
toscope, but  the  most  certain  way  to  locate  it  is  to  pass  a 
probe  through  the  fistula  into  the  anus  or  rectum.  Fistulse 
may  be  blind  internally  or  externally.  In  such  cases  there 
is  no  escape  of  gas  or  fecal  matter,  but  as  long  as  the  orifice 
of  the  fistulous  tract  remains  open,  there  will  be  a  discharge 
of  pus  either  into  the  bowel  or  onto  the  surface  of  the  but- 
tock. When  the  orifice  becomes  closed  a  periproctitic  abscess 
develops. 


PART  Y. 
DISEASES  OF  THE  GENITOURINARY  ORGANS. 


CHAPTER   XXXV. 
DISEASES  OF  THE  KIDNEY. 

GENERAL  CONSIDERATIONS  ON  DIAGNOSIS. 

The  accurate  methods  at  our  disposal  for  the  examination 
of  the  kidneys  and  their  secretion  enable  us  to  ascertain  not 
only  whether  these  organs  are  healthy  or  diseased,  but  also 
in  most  cases  the  exact  nature  of  the  malady  which  affects 
them.  We  are  further  in  a  position  to  ascertain  whether  one 
or  both  organs  are  diseased,  and  if  the  latter  is  the  case, 
which  kidney  is  the  most  affected,  and  finally  we  are  able  to 
determine  the  combined  and  individual  functionating  power 
of  the  two  organs. 

The  health  or  disease  of  the  kidneys  is  determined  from 
a  study  of  the  anamnesis,  from  physical  examination,  from 
careful  urinary  analysis,  from  the  appearances  of  the  ureteral 
mouths  as  seen  with  the  cystoscope,  and  from  x-ray  examina- 
tion. Unilateral  or  bilateral  disease  is  positively  determined 
by  ureteral  catheterization  with  collection  and  examination 
of  the  individual  urines;  and  the  combined  and  individual 
functionating  power  is  ascertained  from  the  total  urea  elimi- 
nated in  twenty-four  hours,  from  the  urea  percentage  in  the 
individual  urines,  from  cryoscopic  examination  of  the  blood, 
cryoscopic  examination  of  the  individual  urines,  and  by  the 
phloridzin  and  methylene-blue  tests. 

The  Anamnesis, — It  is  well  to  remember  that  while  most 
individuals  who  suffer  with  surgical  diseases  of  the  kidney 

24 


370     DISEASES  OF   THE  GENITOURINARY  ORGANS 

afford  at  some  time  clinical  evidences  of  their  malady,  yet 
it  is  not  infrequent  to  see  patients  who  have  been  afflicted 
with  such  ailments  for  a  long  time  without  having  noticed 
anything  abnormal  in  the  urinary  tract  or  urine.  As  only 
the  intelligent  are  accustomed  to  watch  the  gross  appear- 
ances of  the  urine,  it  is  easy  to  understand  how  it  is  that 
even  considerable  grades  of  pyuria  or  hsematuria  pass  un- 
noticed, unless  pain  or  frequent  urination  direct  attention 
to  the  urinary  organs  and  their  excretion.  Such  patients 
often  seek  the  advice  of  the  physician  on  account  of  dis- 
turbances of  their  general  health,  such  as  anaemia,  loss  of 
weight,  or  gastric  and  intestinal  disorders;  their  thorough 
physical  examination  then  reveals  the  existence  of  advanced 
disease  of  one  or  both  kidneys. 

As  a  rule,  however,  the  patients  complain  of  urinary  dis- 
turbances, and  in  every  case  it  is  necessary  to  make  enquiries 
as  to  the  following  facts :  The  frequency  of  urination  (during 
the  day  and  night) ;  whether  it  is  painful  or  not,  and  at  what 
stage  of  the  urinary  act  the  pain  occurs ;  the  gross  appearances 
of  the  urine,  whether  purulent,  or  cloudy,  or  bloody  (and  in 
the  latter  instance  whether  the  urine  is  bright  red  or  smoky 
in  color);  whether  the  pus  or  blood  is  uniformly  distributed 
in  the  urine,  or  whether  it  is  present  only  in  the  first  or  last 
urines ;  the  total  quantity  of  urine  which  is  passed  in  twenty- 
four  hours,  and  the  readiness  or  ease  with  which  the  stream 
is  started. 

All  these  data  are  most  important;  thus  the  only  evidences 
of  early  renal  tuberculosis  may  be  painful,  frequent  urination. 
Pus  or  blood  appearing  only  in  the  first  urines  never  comes 
from  the  kidney;  from  the  latter  source  it  is  always  uniformly 
mixed  with  the  urine.  Smoky  urine  is  believed  by  Gomprecht 
to  indicate  the  kidney  as  the  source  of  the  blood.  Pain 
which  is  experienced  only  at  the  end  of  urination  is  not  due 
to  kidney  disease;  from  this  cause  there  is  pain  throughout 
the  whole  act  of  urination,  though  it  may  be  most  severe  at 
the  beginning  or  end  of  the  act.  Thus  from  a  few  questions 
and  answers  the  examiner  is  able  to  gain  some  insight  into 
the  location  of  the  disease  in  the  urinary  organs. 

In  the  anamnesis  it  is  further  important  to  elicit  such 
general  data  as  may  aid  in  making  the  diagnosis.    Thus  the 


DISEASES  OF   THE  KIDNEY  371 

age  of  the  patient,  the  duration  of  the  symptoms  and  the 
rapidity  with  which  they  have  developed  and  progressed,  the 
existence  of  family  or  personal  tuberculosis,  previous  gonor- 
rhoea or  syphilis,  the  history  of  a  trauma  or  operation  upon 
the  urinary  organs  in  women,  pelvic  inflammation,  pregnancy 
and  child-bearing,  and  the  past  or  present  affliction  with 
other  acute  or  chronic  diseases,  such  as  infections,  pyaemia, 
haemophilia,  etc. 

The  diagnosis,  however,  cannot  be  made  from  the  informa- 
tion which  is  obtained  from  the  anamnesis;  only  a  clue  can 
be  had  from  it  as  to  the  site  and  possible  nature  of  the  urinary 
malady.  The  diagnosis  always  rests  upon  the  knowledge 
which  is  obtained  from  the  examination  of  the  patient  and 
his  urine. 

By  physical  examination  we  can  determine  the  presence  of 
any  abnormal  position,  form,  or  swelling  of  the  kidneys  and 
other  parts  of  the  urinary  tract;  by  chemical  analysis  and 
microscopic  examination  of  the  urine  we  can  determine  the 
presence  of  abnormal  constituents  therein  and  the  amount 
of  urea  which  is  excreted.  With  the  x-ray  we  can  deter- 
mine the  presence  of  foreign  bodies  in  the  urinary  organs; 
with  the  cystoscope  we  can  see  the  appearance  of  the 
ureteral  orifices  and  of  the  vesical  mucosa;  by  ureteral 
catheterization  and  analysis  of  the  separately  collected  urines 
we  can  ascertain  whether  one  or  both  kidneys  are  diseased; 
by  cryoscopy  of  the  blood  we  can  ascertain  the  sufficiency 
or  insufficiency  of  the  combined  kidney  function,  and  by 
cryoscopy  of  the  separated  urines  we  can  find  out  the  indi- 
vidual kidney  functionating  power. 

Physical  Examination. — The  normal  position  of  the 
kidneys  is  retroperitoneal,  in  the  upper  one-third  of  the 
lumbar  fossa,  reaching  from  the  upper  border  of  the  twelfth 
dorsal  vertebra  to  the  lower  border  of  the  second  or  middle 
of  the  third  lumbar  vertebra,  the  right  organ  being  about 
one  finger's  breadth  lower  than  its  fellow.  The  hepatic 
flexure  of  the  colon  covers  the  lower  pole  of  the  right  kidney, 
the  descending  duodenum  its  pelvis;  the  splenic  flexure  and 
tail  of  the  pancreas  cover  the  lower  one-half  of  the  left  kidney, 
and  the  spleen  its  external  lateral  border.  Abnormalities  in 
size,  form,  or  consistency  may  be  detected  by  inspection, 


372     DISEASES  OF   THE  GENITOURINARY  ORGANS 

bimanual  palpation  and  percussion,  with  or  without  pre- 
liminary distention  of  the  stomach  and  colon.  In  palpating 
the  kidney,  the  patient  should  lie  on  his  back,  with  the  lower 
limbs  flexed  and  the  shoulders  slightly  elevated,  or  on  the 
healthy  side  with  limbs  drawn  up,  or  in  the  knee-chest 
position.  The  one  hand  of  the  examiner  is  placed  in  the 
loin  and  the  other  over  the  anterior  abdominal  wall.    Wliere 

Fig. 146 


One  method  of  palpating  kidney.     Patient  in  dorsorecumbent  position,  with  lower 
limbs  flexed  and  shoulders  slightly  elevated. 


the  latter  is  very  rigid,  or  the  individual  very  fat,  a  general 
anisesthetic  may  be  required  in  order  to  make  satisfactory 
palpation.  In  thin  subjects  of  both  sexes  who  have  lax 
abdominal  walls  the  lower  pole  of  the  kidney  may  normally 
be  palpated. 

It  is  always  important  to  ascertain  the  relations  which 
enlargements  and  tumors  of  the  kidney  bear  to  the  colon. 
For  this  purpose  the  colon  should  be  distended  with  air,  and 


DISEASES  OF   THE  KIDNEY 


373 


then  outlined  by  percussion.  On  either  side  the  colon  lies 
in  front  and  internal  to  the  tumor,  the  ascending  colon 
passing  across  it  from  below  and  to  the  right  upward  to  the 
left,  and  the  descending  colon  from  above  and  to  the  left, 
downward  to  the  right. 

Exploratory  Puncture. — Exploratory  puncture  is  often  of 
value  to  ascertain  the  nature  of  the  kidney  swelling.  It 
should  always  be  done  through  the  loin,  and  under  strict 
aseptic  precautions. 

Fig. 147 


Relation  ot  ascending  colon  to  tumor  of  the  right  kidney.    (Winter.) 


Urinary  Examination. — The  importance  of  careful  and 
thorough  urinary  examination  in  establishing  a  diagnosis  of 
kidney  disease  cannot  be  overestimated.  The  total  quantity 
of  urine  which  is  passed  in  twenty-four  hours  should  be 
collected  and  a  specimen  thereof  examined  chemically  and 
microscopically.  Its  reaction  and  color  and  the  presence  of 
sediment  should  be  noted.  If  there  is  a  sediment,  the  urine 
should  be  repeatedly  filtered  until  it  is  clear,  the  filtered  urine 
being  examined  for  albumin  and  sugar,  and  urea  percentage, 
and  the  sediment  being  examined  under  the  microscope  for 
crystals  of  uric  acid,  oxalates,  triple  phosphates,  leucin,  and 


374     DISEASES  OF   THE  GENITOURINARY  ORGANS 

tyrosin,  for  pus  and  red  blood  cells/  casts,  epithelia,  and 
micro-organisms,  especially  tubercle  bacilli,  staphylococci, 
streptococci,  or  colon  bacilli.  (Examination  of  the  urine  for 
the  presence  of  bacteria  always  demands  that  it  be  drawn 
by  aseptic  catheter.)  The  methods  of  performing  these  tests 
and  the  appearance  of  the  microscopic  elements  are  to  be 
obtained  from  books  on  urinary  examination. 

Cystoscopic  Examination. — -The  appearance  of  the  ure- 
teral openings  as  seen  with  the  cystoscope  and  the  character 
of  the  urinary  efflux  are  valuable  aids  in  making  a  diagnosis 
of  the  presence  and  nature  of  a  kidney  affection.  Naturally 
a  trained  eye  is  essential  to  appreciate  the  changes  in  the 
shape,  position,  and  appearance  of  the  ureteral  orifice,  and 
considerable  experience  is  necessary  to  interpret  the  cysto- 
scopic findings.  If,  however,  we  are  to  establish  an  early 
diagnosis  in  obscure  cases  we  must  have  the  aid  of  all  the 
data  which  it  is  possible  to  collect,  and  some  of  the  most 
important  of  these  data  are  to  be  obtained  only  by  cystoscopic 
examination.  Though  it  is  impossible  from  our  present 
experience  to  state  exactly  what  kidney  changes  and  lesions 
correspond  to  the  appearances  of  the  ureteral  orifices,  still 
there  are  certain  cystoscopic  pictures  which  are  known  to 
be  due  to  definite  kidney  affections.  The  following  descrip- 
tions of  the  ureteral  orifice  in  health  and  disease  and  the 
clinical  significance  of  the  changes  in  its  appearance  and 
position  are  for  the  most  part  taken  from  Hurry  Fenwick 
(Obscure  Diseases  of  the  Kidneys),  a  pioneer  observer  in  this 
new  field  of  diagnosis. 

In  practising  ureteral  meatoscopy  the  observer  should  note 
the  position  of  the  ureteral  orifice,  its  shape  and  size,  and 
the  appearance  of  the  surrounding  and  adjacent  vesical 
mucosa.  The  normal  ureteral  orifice  lies  in  the  lateral  angle 
of  the  trigonum,  on  a  slightly  elevated  hillock,  and  appears 
as  a  faint,  flesh-colored  slit,  or  rounded  hole. 

The  ureteral  orifice  may  become  elongated  and  furrowed, 
arched,  dilated  like  a  golf-hole,  puckered,  distorted,  and 
warped;  its  mucous  membrane  may  be  congested,  oedematous. 


1  The  shape  of  the  red  blood  cells  is  important  as  aflfording  a  hint  to  their  source  ; 
thus  crenated  cells  come  from  the  higher  urinary  organs. 


PLATE  III. 


Cystoscopie  Pictures  of  the  Normal  Bladder  and 
Ureteral  Orifices.     (From  Nitze.) 

A.  Appearance  of  fhe  normal  vesical  mucosa. 

B.  Trigonum  and  adjoining  portion  of  the  base  of  the  bladder.  The  darker  lower  half  repre- 
sents the  trigonum.  Note  the  unbroken  slightly  concave  line  of  the  normal  prostate  which  separates 
the  trigonum  from  the  remaining  portion  of  the  vesical  floor. 

G.  and  D.  Different  varieties  of  the  normal  ureteric  orifice.  In  C.  the  ureteric  bar  is  very  strongly 
marked. 

Note  the  position  of  the  orifice  in  the  lateral  angle  of  the  trigonum. 


DISEASES  OF   THE  KIDNEY  375 

eroded,  ulcerated,  or  the  seat  of  pinhead  to  pea-sized  papil- 
lomata,  or  everted  or  prolapsed  into  the  bladder. 

Elongation  of  the  orifice  indicates  a  dilatation  of  the  kidney 
pelvis,  while  an  arched  shape  points  to  dilatation  of  the 
ureter  -from  below  upward,  as  occurs  whenever  there  is  an 
obstruction  to  the  free  passage  of  urine  through  the  urethra. 

The  golf-holed  orifice  corresponds  to  a  dilated,  atonic 
kidney  pelvis  and  ureter,  and  conical  protrusion  usually 
points  to  a  kidney-stone  which  provokes  colics. 

With  the  painless  hcematuria  which  results  from  chronic 
granular  nephritis,  malignant  disease,  aseptic  calculus,  and 
some  forms  of  tuberculosis,  the  ureteral  orifice  may  be 
elongated  and  furrowed  from  distention  of  the  kidney  pelvis 
with  blood,  and  somewhat  congested  as  though  streaked  with 
fresh  blood,  or  it  may  be  unaltered. 

With  renal  calculus  the  appearance  of  the  ureteral  orifice 
varies.  In  some  cases  there  is  no  change;  if  the  pelvis  is  di- 
lated, the  orifice  is  elongated  and  furrowed,  possibly  congested; 
and  if  there  is  pyelitis  with  alkaline  urine,  there  are  scald-like 
erosions  and  congestion  of  the  immediate  area  around  the 
orifice,  its  lips  being  everted  and  the  trigonum  congested  and 
swollen;  ultimately  the  orifice  becomes  warped  and  contracted. 
With  pyelitis  the  eflflux  is  muddy,  the  jets  of  urine  being 
forcible  and  rapidly  repeated  or  slow  and  sluggish.  If  there 
is  entire  cessation  of  the  function  of  the  kidney  from  coincident 
suppuration,  the  ureteral  orifice  is  golf-holed  and  the  eflflux 
is  slow  and  consists  of  solid  or  semisolid  pus.  If  a  stone  is 
passing  through  the  ureter  and  is  near  its  vesical  end,  there 
may  be  punctate  extravasations  in  the  immediate  neigh- 
borhood of  the  orifice,  and  the  corresponding  side  of  the 
interureteric  bar  becomes  thick  and  swollen;  as  the  stone 
approaches  nearer  the  bladder  the  extravasations  become 
more  numerous,  until  finally  the  orifice  and  its  immediate 
surroundings  become  uniformly  red  and  appear  to  be 
bruised.  Sometimes  there  is  considerable  cedema.  After  the 
transit  of  the  stone  the  orifice  may  be  oedematous ;  it  is  large 
and  patulous  if  the  stone  was  smooth,  eroded  and  irregular 
if  rough,  and  the  surrounding  area  is  red.  If  the  stone  is 
arrested  in  the  lower  third  of  the  ureter,  the  mucous  mem- 
brane of  the  orifice  is  protruded  and  everted,  sometimes 


376     DISEASES  OF   THE  GENITOURINARY  ORGANS 

roughened,  again  oedematous;  the  efflux  may  be  perfectly 
normal. 

With  renal  tuberculosis  there  may  be  no  changes  in  the 
ureteral  orifice.  In  the  early  stages  of  the  disease  the  open- 
ing is  usually  golf-holed;  all  around  it  the  mucous  membrane 
is  reddened,  and  on  it  are  to  be  seen  a  few  sparsely  scattered 
tubercles,  and  not  infrequently  there  are  one  or  more  sharply 
cut,  sloughing  ulcers  behind  the  affected  orifice;  on  the  rest 
of  the  vesical  mucosa  further  evidences  of  tuberculosis  may 
be  present,  in  the  shape  of  red,  extravasated  areas  with 
white,  necrotic  flakes  on  them  or  superficial  erosions  or  worm- 
eaten  ulcerations.  In  more  advanced  tuberculosis  the  ureter 
and  corresponding  part  of  the  bladder  wall  are  dragged  out 
of  their  normal  position,  and  ulcerations  with  red  patches  of 
extravasation  are  visible  on  other  parts  of  the  bladder  wall; 
the  orifice  is  patulous  and  irregular  in  shape,  and  its  wall 
is  thick  and  caked;  or  the  orifice  is  thickened,  irregular,  and 
choked,  or  the  seat  of  massive  oedema,  the  latter  being  prob- 
ably the  result  of  an  acute  tuberculous  pyelitis. 

With  neoplasm  the  orifice  may  be  elongated  and  furrowed 
from  distention  of  the  kidney  pelvis. 

If  the  peristaltic  wave  at  the  ureteral  orifice  is  strongly 
marked,  the  lips  of  the  opening  being  drawn  in,  and  the 
urine  forcibly  ejected,  it  indicates  an  hypertrophy  and  some 
dilatation  of  the  ureter  from  increased  work  of  the  corre- 
sponding kidney,  or  from  irritation  of  the  ureter  by  a  foreign 
body — e.  g.,  a  calculus  or  blood  clot  or  plug  of  mucus  and 

An  efflux  of  clear  urine  appears  like  a  wave  of  glycerin 
passing  inward  across  the  trigonum.  The  efflux  may  be 
clear  or  opaque  (bloody  or  purulent),  rapidly  repeated  and 
forcible  or  slow  and  trickling.  A  puriform  trickle  indicates 
a  crippled,  suppurating  kidney;  a  blood  trickle  points  to  a 
crippled  kidney  or  to  a  moderate  hemorrhage  with  diminished 
secretion  of  urine  by  the  affected  organ.  A  solid  pus  efflux 
indicates  secretory  death  of  the  corresponding  suppurating 
kidney;  a  solid  bloody  efflux  points  to  a  profuse  renal 
hemorrhage. 

X-ray  Examination. — X-ray  examination  is  especially  im- 
portant for  detecting  and  locating  calculi  within  the  urinary 


DISEASES  OF   THE  KIDNEY 


377 


passages.    Neoplasms  may  be  recognized  as  deeper  shadows 
surrounded  by  lighter  areas. 


Fig. 148 


5l 


^ 


-rrr 


-^ 


e 
d 
c 


■////  .,,. ,,■'///////////.. v'///yy///////Z'y J 


Beckmann's  freezing  apparatus.    (Von  Bergmann.) 


378     DISEASES  OF   THE  GENITOURINARY  ORGANS 

Determination  of  Kidney  Function. — The  determination 
of  kidney  function  is  especially  important  when  operative 
attack  upon  these  organs  is  contemplated.  No  surgeon  is 
justified  at  the  present  time  in  planning  to  remove  one  kid- 
ney or  even  to  incise  one  except  for  the  relief  of  anuria, 
unless  he  has  previously  ascertained  the  combined  and 
individual  functionating  capacity  of  these  organs. 

The  combined  functionating  capacity  is  determined  by 
cryoscopic  examination  of  the  blood,  and  of  a  specimen  of 
the  total  twenty-four-hour  urine,  during  which  period  mod- 
erate amounts  of  fluid  have  been  ingested,  and  from  the 
amount  of  urea  which  is  eliminated  in  twenty-four  hours. 
The  individual  functionating  capacity  is  determined  by 
cryoscopic  examination  of  the  separated  urines  and  from 
the  amount  of  urea  which  is  contained  in  the  separated 
urines,  and  the  relative  functionating  capacity  of  the  two 
organs  is  determined  by  comparing  the  percentages  of  sugar 
which  are  contained  in  the  individual  urines  after  a  subcu- 
taneous injection  of  phloridzin.^ 

The  cryoscope  that  is  in  general  use  is  that  designed  by 
Beckmann.     Its  essential  parts  are  a  vessel  (a)  to  hold  the 

1  There  is  at  present  no  unanimity  of  opinion  as  to  the  relative  value  of  these 
methods  for  determining  the  functional  capacity  of  the  kidneys.  Some  (Israel, 
Roosing,  and  others)  maintain  that  the  best  indicator  of  a  combined  and  individual 
sufficient  kidney  function  is  the  percentage  of  urea  in  the  total  twenty-four-hour 
urine,  and  in  the  separated  urines  respectively;  whereas  others  (Casper,  Kummel, 
and  others)  believe  that  cryoscopy  of  the  blood  and  of  the  combined  and  separated 
urines  furnishes  the  best  data  as  to  the  kidney  iunction.  The  author  uses  both 
methods,  and  with  one  exception  has  never  been  deceived  as  to  the  functional 
capacity  of  the  kidneys. 

After  all,  it  is  functional  capacity  of  the  individual  kidneys  that  concerns  us  most 
when  operative  attack  upon  these  organs  is  contemplated.  It  would  be  manifestly 
wrong  to  remove  one  kidney  or  severely  injure  It  if  the  opposite  kidney  were  seri- 
ously diseased  and  of  insufficient  functionating  capacity.  We  must  not,  however, 
accept  blindly  nor  rest  our  decision  for  or  against  operation  upon  the  knowledge 
of  kidney  function  afforded  us  by  the  percentage  of  urea,  or  by  the  freezing  point  of 
the  urine  and  blood.  Thus,  very  often  a  perfectly  healthy  kidney  works  insuffici- 
ently because  of  disease  of  its  fellow-organ.  Such  a  kidney  will  resume  its  normal 
sufficient  action  when  the  diseased  organ  is  removed.  When,  therefore,  in  a  case  of 
contemplated  nephrectomy  the  urine  drawn  from  the  opposite  kidney  shows  it  to  be 
the  seat  of  no  serious  organic  disease,  we  proceed  to  operation,  even  though  its  urea 
output  and  the  cryoscopic  index  of  its  urine  and  of  the  blood  indicate  an  insufficient 
function  on  its  part,  and  thus  speak  against  removal  of  the  one  organ.  Each  case  of 
kidney  disease  must  be  studied  by  itself,  and  not  only  must  we  endeavor  to  ascertain 
the  combined  and  individual  functionating  power  of  the  two  organs,  but  the  causa- 
tion of  abnormalities  in  this  latter  respect  must  likewise  be  sought. 


DISEASES  OF  THE  KIDNEY  379 

freezing  mixture,  a  glass  air-chamber  (b),  closed  at  the  top 
with  a  perforated  cork  through  which  passes  a  test-tube  (e) 
to  contain  the  fluid,  whose  freezing  point  is  to  be  determined. 
This  last  test-tube  (e)  is  also  closed  at  the  top  with  a  double 
perforated  cork,  one  of  the  openings  being  for  the  Beckmann 
thermometer  (h)  and  the  other  for  a  platinum  glass  stirrer  (g). 
(The  function  of  the  latter  is  to  enable  us  to  keep  the  entire 
solution  that  is  to  be  frozen  at  a  uniform  temperature.) 
The  thermometer  is  peculiarly  constructed.  It  has  at  the 
top  a  mercury  reservoir,  which  is  connected  by  a  U-tube  with 
the  tube  of  the  thermometer.  From  the  reservoir  sufficient 
mercury  is  shaken  up  into  the  U-tube  so  that  the  thermometer 
will  register  the  freezing  point  of  distilled  water  somewhere 
near  the  middle  of  the  graduated  portion.  The  graduations 
are  in  degrees,  which  are  again  subdivided  into  100  parts. 
It  is  very  important  to  bear  in  mind  that  this  thermometer 
is  not  meant  to  register  the  temperature  of  the  solution  which 
is  to  be  frozen.  It  is  designed  to  register  the  point  at  which 
various  fluids  freeze,  so  that  their  freezing  point  can  be 
compared  with  that  of  distilled  water.  This  latter  point  on 
the  thermometer  scale  is  not  a  fixed  one,  but  depends  entirely 
upon  the  amount  of  mercury  which  we  shake  up  into  the 
U-tube  at  the  top  of  the  thermometer.  We  try  to  have 
sufficient  mercury  in  this  tube  so  that  the  thermometer  will 
register  the  freezing  point  of  distilled  water  somewhere  near 
the  middle  of  its  graduated  section. 

The  freezing  point  of  water  on  the  thermometer  scale 
is  to  be  determined  first  of  all,  and  then  the  freezing  point 
of  the  other  solution;  their  difference  represents  the  cryo- 
scopic  coefficient  of  the  latter.  We  should  use  sufficient 
solution  to  completely  cover  the  bulb  of  the  thermometer. 
As  a  freezing  mixture,  ice  and  salt  or  a  solution  of  am- 
monium nitrite  in  water  will  answer  every  purpose.  Dur- 
ing the  freezing  process  the  platinum  glass  stirrer  is  worked 
continually  up  and  down,  so  as  to  maintain  a  uniform  tem- 
perature of  the  solution  that  is  to  be  frozen.  As  the  freez- 
ing proceeds  the  mercury  will  be  noticed  to  fall  in  the 
tube,  and  after  reaching  a  certain  level  it  suddenly  rises 
and  remains  at  a  fixed  point.  The  latter  point  is  the 
freezing  point,  the  fall  below  this  being  due  to  the  fact  that 


380     DISEASES  OF   THE  GENITOURINARY  ORGANS 

the  solution  undercools  before  it  really  solidifies.  If  the 
freezing  is  continued  with,  the  mercury  will,  of  course,  con- 
tinue to  fall  as  we  lower  the  temperature  of  the  ice.  The 
freezing  point  of  a  solution  depends  on  the  amount  of  its 
dissolved  molecules.  It  is  evident  that  with  insufficient 
kidney  function  the  dissolved  molecules  in  the  blood  which 
normally  should  be  eliminated  by  the  kidneys  remain  to  a 
greater  or  less  extent  in  solution  in  the  blood,  and  conse- 
quently the  molecular  concentration  of  the  latter  rises,  with 
corresponding  lowering  of  its  freezing  point;  and  conversely 
the  molecular  concentration  of  the  urine  diminishes  with 
consequent  elevation  of  its  freezing  point  as  compared  with 
that  of  distilled  water,  which  is  taken  as  a  standard. 

The  blood  with  normally  functionating  kidneys  freezes  at 
0.56°  C.  below  distilled  water;  variations  to  0.60°  C.  are 
within  the  limits  of  normality.  If  the  freezing  point  falls 
below  0.60°  C.  renal  insufficiency  may  be  inferred.  It  is  to 
be  noted,  however,  that  the  freezing  point  may  be  below 
0.60°  C.  as  a  result  of  heart  disease,  or  from  increased  intra- 
abdominal pressure  occasioned  by  large  tumors,  or  from 
insufficient  oxidation  of  the  blood  on  account  of  respiratory 
disease,  or  during  severe  one-sided  renal  pain,  even  though 
one  or  both  kidneys  are  healthy;  due  allowance  must  be 
made  in  such  conditions  for  the  lowering  of  the  freezing 
point. 

The  urine  normally  freezes  at  1.2°  C.  to  2.2°  C.  below 
distilled  water.  With  renal  insufficiency  the  freezing  point 
of  the  urine  approaches  or  equals  that  of  the  blood.  With 
ingestion  of  large  amounts  of  water  the  freezing  point  of  the 
urine  rises  even  to  0.1°  C,  and  with  ingestion  of  little  water 
the  freezing  point  falls  to  3°  C.  The  freezing  point  of 
urine  should,  therefore,  be  determined  only  after  a  moderate 
ingestion  of  fluids.  If,  under  such  circumstances,  the 
freezing  point  is  less  than  1°  C.  and  no  severe  anaemia  is 
present,  renal  insufficiency  must  be  assumed. 

By  catheterizing  the  ureters  and  collecting  the  secretion 
of  each  kidney  separately,  and  then  ascertaining  their  indi- 
vidual freezing  points,  we  may  by  comparing  the  two  results 
determine  the  functional  activity  of  each  organ;  and  as  the 
functionating  activity  of  an  organ  depends  on  the  amount  of 


DISEASES  OF   THE  KIDNEY  381 

secreting  structure  in  it,  we  may,  also  from  a  comparison  of 
the  individual  freezing  points  of  the  urines  of  two  diseased 
kidneys,  ascertain  which  organ  is  most  diseased. 

The  individual  functional  activity  may  also  be  determined 
by  the  methylene-blue  and  phloridzin  tests,  combined  with 
the  separate  collection  of  the  urines  with  the  ureteral  catheter. 
Of  the  two  tests  the  phloridzin  is  the  more  rapid  and  reliable. 
To  carry  out  this  test  both  ureters  are  catheterized  and  then 
0.005  gm.  of  phloridzin  is  injected  subcutaneously  into  the 
buttock;  the  amount  of  sugar  eliminated  during  the  same 
time  by  each  kidney  is  then  to  be  determined. 

Healthy  organs  eliminate  from  phloridzin  the  same  amount 
of  sugar  at  the  same  time.  By  comparing,  therefore,  the 
percentage  of  sugar  eliminated  by  each  kidney  during  the 
same  period  it  is  possible  to  determine  the  amount  of  working 
parenchyma  in  each  organ. 

(Note. — In  the  methylene-blue  test — which  is  made  by 
injecting  0.05  gm.  of  methylene  blue  into  the  buttock  after 
preliminary  catheterization  of  the  ureters — ^it  is  necessary  to 
watch  for  the  beginning  of  the  elimination,  its  cessation,  its 
course,  and  its  intensity.  As  the  elimination  may  extend 
over  three  days,  during  which  time  the  ureteral  catheters 
would  have  to  remain  in  place,  this  method  is  not  as  good 
a  one  as  the  phloridzin.) 


CHAPTER   XXXVI. 

MALFORMATIONS  AND  DISPLACEMENTS  OF  THE 
KIDNEY. 

CONGENITAL  MALFORMATIONS  OF  THE  KIDNEY. 

Absence  of  One  Kidney. — Absence  of  one  kidney  can  only 
be  diagnosed  by  the  impermeability  of  the  corresponding 
ureter  in  the  whole  or  part  of  its  extent,  and  by  the  absence 
of  urinary  secretion  from  this  ureter. 

Fusion. — Fusion  of  the  organs  into  one  horseshoe  kidney 
or  into  an  elongated  kidney  can  be  recognized  in  thin  indi- 
viduals by  palpation,  especially  if  the  organ  is  movable. 
An  increased  number  of  ureteral  openings  in  the  bladder 
or  other  deformities  of  the  urogenital  system  should  excite 
our  suspicions  of  such  congenital  malformations  of  the 
kidney.  If,  on  exposure  of  one  organ,  it  is  found  to  be 
abnormally  large,  the  suspicion  of  an  abnormality  in  the 
number  of  kidneys  should  be  entertained. 

Congenital  Sacral  Kidneys. — Congenital  sacral  or  'pelvic 
kidneys,  which  are  distinguished  by  their  fixed  position  from 
floating  kidneys  that  may  lie  in  these  regions,  should  be 
recognized  by  their  pyramidal  form  and  their  lobulation. 
They  attract  attention  only  when  they  become  inflamed  or 
swollen,  or  when  they  exert  pressure  upon  the  pelvic  organs. 

Two  or  More  Ureters. — Two  or  more  ureters  on  one  side 
can  be  made  out  with  the  cystoscope,  provided  the  accessory 
ureters  have  a  vesical  opening  into  which  a  catheter  can  be 
passed.  If  the  accessory  ureter  opens  into  its  fellow  the 
diagnosis  cannot  be  made.  If  the  accessory  ureter  opens 
into  the  urethra  or  seminal  passages,  the  diagnosis  may  be 
made  from  the  history  of  constant  dripping,  in  spite  of  which 
the  patient  is  still  able  to  urinate  voluntarily  in  a  stream. 


NEPHROPTOSIS  AND  REN  MOBILIS     .  383 

A  pouch-like,  miicous-membrane-covered  tumor  which  Kes 
in  the  bladder  or  urethra  and  which,  in  the  latter  instance, 
can  be  replaced  into  the  bladder,  and  which  on  cystoscopic 
examination  is  seen  to  spring  from  the  region  of  the  ureteral 
orifice,  suggests  a  cystic  intraparietal  dilatation  of  the  vesical 
end  of  the  ureter. 


NEPHROPTOSIS  AND  REN  MOBILIS. 

A  movable  kidney  is  readily  recognized  by  its  kidney  shape, 
its  hilus,  and  its  easy  reposition  into  the  loin,  a  position  that 
it  maintains  as  long  as  the  patient  remains  recumbent  and 
does  not  strain.  Such  a  movable  kidney  may  provoke  no 
symptoms,  or  it  may  occasion  a  dragging  or  colicky  pain  in 
the  side,  nausea,  vomiting,  constipation,  and  occasionally 
jaundice.  In  some  cases  the  pain  is  referred  to  the  appen- 
dicular region,  and  this  may  occasion  the  belief  that  the 
patient  has  appendicitis.  As  chronic  affections  of  the  colon 
and  appendix  are  frequently  combined  with  nephroptosis, 
the  only  way  we  can  decide  whether  the  symptoms  are  due 
to  the  floating  kidney  alone  is  to  support  the  kidney  by  a 
belt  and  see  whether  they  disappear. 

The  kidney  may  be  the  only  abdominal  organ  that  is  loose 
and  prolapsed,  or  there  may  be  a  general  visceral  ptosis,  the 
latter  constituting  Glenard's  disease.  Patients  who  suffer 
from  this  latter  malady  are,  as  a  rule,  thin,  anaemic  indi- 
viduals who  complain  of  gastric  dyspepsia,  constipation, 
general  bodily  aches  and  pains,  general  lassitude  and  other 
neurasthenic  symptoms.  As  the  prolapse  of  the  kidney  in 
these  cases  is  but  one  of  the  disturbances  from  which  the 
patient  suffers,  it  is  evident  that  nephropexy  will  do  no 
material  good,  and  therefore  before  proceeding  to  anchor 
a  kidney  we  should  always  ascertain  whether  this  organ 
alone  or  whether  all  the  abdominal  organs  are  prolapsed. 
This  can  readily  be  done  by  outlining  the  limits  of  these 
organs  by  percussion  and  palpation,  a  preliminary  distention 
of  the  stomach  and  colon  affording  considerable  aid  in  this 
examination. 

It  sometimes  happens  that  the  ureter  of  a  floating  kidney 


384     DISEASES  OF   THE  GENITOURINARY  ORGANS 

becomes  kinked,  or  that  its  pedicle  becomes  twisted.  In  the 
former  instance  the  kidney  becomes  enlarged  and  tender 
(acute  hydronephrosis)  and  the  patients  have  colicky  pains 
in  the  loin  and  sometimes  hsematuria;  all  of  these  symptoms 
disappear  when  the  ureter  becomes  straightened  out.  Such 
attacks  may  be  repeated  from  time  to  time,  thus  causing  an 
intermittent  hydronephrosis. 

Strangulation  of  the  kidney  from  twist  in  the  pedicle 
occasions  sudden  intense  pain  with  nausea,  vomiting,  faint- 
ness;  even  collapse,  chills,  and  fever.  The  kidney  is  enlarged, 
tender,  and  painful,  and  the  amount  of  urine  which  is  voided 
is  considerably  diminished. 

A  movable  kidney  may  be  confounded  with  an  accessory 
hepatic  lobe,  with  cysts  of  the  liver,  and  with  gall-bladder 
enlargements.  All  tumors  of  the  liver  and  gall-bladder  share 
the  respiratory  mobility  of  these  organs,  whereas  floating 
kidneys,  except  they  have  a  long  pedicle  and  a  mesentery, 
have  no  respiratory  mobility.  The  kidney  is  usually  covered 
by  the  colon,  which  gives  tympanitic  resonance,  whereas  the 
gall-bladder  and  liver  lie  close  to  the  anterior  abdominal 
wall  and  the  percussion  note  over  them  is  dull.  The  most 
conclusive  sign  for  differentiation  lies  in  the  ease  with  which 
a  floating  kidney  can  be  replaced  into  the  loin,  which  position 
it  furthermore  maintains  when  pressure  upon  it  is  relaxed, 
whereas  all  other  tumors  and  swellings  cannot  be  fully 
pushed  into  the  loin  and  on  their  relaxation  at  once  come 
out  again. 

A  floating  spleen  or  enlarged  spleeii  is  differentiated  from 
a  floating  kidney  by  its  characteristic  form  and  its  notched 
anterior  border. 

Tumors  of  the  stomach  and  colon  cannot  be  fully  replaced 
into  the  loin,  and  they  furthermore  afford  other  clinical 
evidences  that  enable  us  to  readily  differentiate  them  from 
floating  kidneys;  thus  with  pyloric  tumors  of  a  malignant 
character  there  are  the  manifestations  of  pyloric  stenosis  and 
the  gastric  juice  contains  no  free  hydrochloric  acid,  but  does 
contain  lactic  acid,  and  with  benign  pyloric  tumors  the 
evidences  of  stagnation  within  the  stomach,  with  or  without 
changes  in  the  chemical  composition  of  the  gastric  juice,  are 
present.     (See  p.  270.) 


NEPHROPTOSIS  AND  REN  MOBILIS  385 

With  intestinal  tumors  that  cause  stenosis  of  the  affected 
loop  of  bowel  there  are  the  evidences  of  chronic  intestinal 
obstruction.  (See  p.  283.)  In  doubtful  cases  distention  of 
the  stomach  and  colon  will  throw  light  on  the  site  and  origin 
of  the  tumor. 

Long-pedicle  tumors  of  the  ovaries  may  have  the  same 
shape  and  consistency  as  the  kidneys,  but  they  cannot  be 
fully  replaced  into  the  loin,  and  on  vaginal  examination  the 
pedicle  of  the  tumor  can  be  easily  appreciated. 


25 


CHAPTER   XXXVII. 
INFLAMMATIONS  OF  THE  KIDNEY. 

SUPPURATIVE  NEPHRITIS. 

Acute  Abscesses. — Of  the  acute  abscesses  of  the  kidney 
the  large  single  or  multiple  ones  are  readily  recognized  from 
the  following  signs :  A  palpable  enlargement  and  tenderness 
of  the  organ,  associated  with  colicky  pain  in  the  side,  pyuria 
and  moderately  severe  constitutional  manifestations  of  sepsis, 
such  as  repeated  chills,  continuous  or  intermittent  fever, 
rapid  pulse,  profuse  sweating,  rapid  emaciation,  and  high 
leukocyte  count.  Such  abscesses  are  most  frequently  trace- 
able to  suppurations  in  other  parts  of  the  body,  and  espe- 
cially to  furuncles  and  acute  osteomyelitis  of  the  fingers  and 
toes.  The  recognized  frequency  of  kidney  infection  in  such 
diseases  should  be  ever  kept  in  mind,  and  it  should  prompt 
us  to  carefully  examine  these  organs  when  during  their  course 
the  general  constitutional  symptoms  point  to  other  foci  of 
suppuration. 

The  acute  miliary  abscesses  of  the  kidney,  a  pathological 
condition  of  the  organ  that  is  better  known  to  us  as  "surgical 
kidney,"  are  especially  apt  to  follow  operations  upon  the 
lower  urinary  organs  and  the  acute  infectious  diseases. 
Their  presence  is  to  be  strongly  suspected  when,  in  these 
conditions,  there  is  colicky  pain  in,  some  tenderness  over, 
and  possibly  some  enlargement  of  the  kidneys,  together  with 
severe  constitutional  symptoms. 

Chronic  Abscesses. — It  is  but  too  commonly  considered 
that  suppuration  within  the  kidney  is  always  attended  with 
pyuria,  swelling  of  the  organ,  and  more  or  less  severe  consti- 
tutional symptoms.  This  is  by  no  means  the  case,  for  it  not 
infrequently  happens  that  one  or  several  abscesses  are  present 
in  the  cortex  of  the  kidney  without  there  being  any  constitu- 


INFLAMMATIONS   OF    THE  KIDNEY  387 

tional  or  local  symptoms  or  pus  in  the  urine  to  indicate  their 
presence.  In  such  instances  the  abscesses  are  small,  and 
not  in  communication  with  the  kidney  pelvis,  and  the 
organisms  which  have  excited  the  suppuration  have  little  or 
no  virulence.  Such  cases  of  latent  kidney  abscesses  have 
no  interest  to  us,  for  the  lack  of  all  constitutional  or  local 
disturbances  precludes  the  possibility  of  their  coming  under 
treatment.  In  most  instances,  however,  the  abscesses  sooner 
or  later  rupture  into  the  pelvis  of  the  kidney,  and  from 
the  clinical  picture  that  is  then  afforded  the  diagnosis  is 
readily  made.  The  patients  are  thin,  anaemic,  and  weak, 
and  have  a  slight  evening  rise  of  temperature;  the  kidneys 
are  enlarged,  somewhat  tender,  and  excite  colicky  pain  in  the 
loin;  urination  is  frequent  and  the  urine  contains  considerable 
quantities  of  pus.  The  cystoscopic  appearances  of  the 
ureteral  orifices  help  to  confirm  the  diagnosis.  Thus,  soon 
after  the  rupture  of  the  abscess  into  the  kidney  pelvis  has 
occurred  the  ureteral  orifices  appear  congested,  scalded,  and 
eroded,  the  efflux  being  muddy  and  forcible;  later  on  the 
orifice  is  contracted,  irregular  and  warped,  and  the  efflux  is 
slower  and  thicker — indications  that  the  function  of  the 
kidney  is  being  destroyed;  and  finally  the  efflux  becomes  a 
solid,  puriform  trickle — an  indication  of  the  secretory  death 
of  the  kidney.  The  remaining  vesical  mucosa  shows  the 
evidences  of  chronic  cystitis. 

While  it  is  easy  to  make  the  diagnosis  of  suppurating 
kidney  at  this  stage,  it  is  not  always  as  easy  to  determine 
whether  the  suppuration  was  the  primary  malady  or  whether 
it  was  engrafted  upon  a  preceding  tuberculous  or  calculous 
condition.  The  previous  history  may  afford  us  a  clue  as  to 
this  point.  Thus  a  chronic  suppuration  in  some  other  part 
of  the  body,  especially  the  lower  urinary  organs,  will  suggest 
a  primary  suppurative  process,  whereas  the  history  of  pre- 
vious attacks  of  kidney  colic  with  hsematuria,  or  a  history 
that  goes  with  tuberculosis  of  this  organ  (for  which  see 
p.  391)  would  rather  indicate  a  secondary  pyogenic  infec- 
tion upon  a  pre-existing  stone  or  tuberculous  condition.  The 
presence  of  tubercle  bacilli  in  the  urine  and  the  characteristic 
tuberculous  lesions  around  the  ureteric  orifice  and  on  the 
vesical  mucosa  are  conclusive  evidences  of  a  mixed  tuber- 


388     DISEASES  OF   THE   GENITOURINARY  ORGANS 

culous  and  pyogenic  infection,  and  similarly  the  shadows  of 
stones  in  the  affected  kidney  as  shown  by  the  x-ray  affords 
us  positive  proof  of  a  combined  pyogenic  and  calculous 
condition. 

The  absence  of  a  fluctuating  tumor  which  varies  in  size 
from  time  to  time,  the  fluctuations  in  size  being  coincident 
with  a  diminution  or  disappearance  of  or  increase  in  the 
amount  of  pus  in  the  urine,  distinguishes  abscesses  of  the 
kidney  from  pyonephrosis. 

Some  cases  of  surgical  kidney  do  not  manifest  the  local 
evidences  which  were  described  above  as  going  with  this  con- 
dition; they  exhibit  only  the  constitutional  symptoms,  and 
as  these  simulate  those  which  are  occasioned  by  acute 
miliary  tuberculosis,  typhoid  fever,  and  cerebrospinal  menin- 
gitis, we  must  carefully  exclude  these  maladies  before  decid- 
ing upon  a  diagnosis  of  surgical  kidney. 


HYDRONEPHROSIS  AND  PYONEPHROSIS. 

Distention  of  the  kidney  pelvis  with  fluid  is  the  charac- 
teristic sign  by  which  we  distinguish  hydronephrosis  and 
pyonephrosis.  In  the  former  clear  urine  is  the  distending 
material,  and  in  the  latter  pus  and  urine.  Such  a  distention 
is  always  due  to  an  obstruction  in  the  ureter,  bladder,  or 
urethra,  which  interferes  with  the  free  drainage  of  the  kidney 
pelvis.  This  obstruction  may  be  a  continuously  acting  one 
— e.  g.,  a  cancer  of  the  uterus  which  compresses  the  ureter 
or  a  stricture  of  the  ureter  or  urethra;  or  it  may  be  present 
only  at  times — e.  g.,  a  kink  in  the  ureter  or  a  calculus  which 
intermittently  blocks  the  ureter;  in  the  former  instance  the 
distention  is  constant,  and  in  the  latter  it  is  intermittent. 

An  acute  onset  of  exquisite  pain  in  the  kidney,  which 
becomes  enlarged  and  stony  hard,  together  with  moderate 
fever,  prostration,  and  diminution  in  the  amount  of  urine 
which  is  voided,  is  indicative  of  an  acute  hydronephrosis.  A 
large,  gradually  developing,  smooth,  fluctuating  sac  that  is 
attended  only  with  vague  gastrointestinal  symptoms,  such  as 
nausea,  loss  of  appetite,  thirst  and  constipation,  points  to  a 
chronic  hydronephrosis. 


INFLAMMATIONS  OF    THE  KIDNEY  389 

An  acutely  enlarged,  painful  tumor  in  which  fluctuation 
may  be  obtained,  with  continuous  or  hectic  fever  with  or 
without  chills,  emaciation,  loss  of  appetite,  profuse  sweats, 
and  high  leukocyte  count,  etc.,  speak  for  acute  pyonephrosis, 
and  a  more  slowly  forming  tumor  with  gradual  deterioration 
of  the  general  health  and  moderate  fever  point  to  a  chronic 
pyonephrosis. 

During  an  attack  of  acute  hydronephrosis  the  urine  is 
diminished  in  amount,  but  it  is  clear  and  appears  normal. 
The  opposite  kidney  if  healthy  may  take  up  the  function  of 
the  obstructed  one  or  it  may  itself  suspend  function,  in  which 
case  anuria  results.  Between  the  attacks  the  urine  is  normal, 
both  in  amount  and  in  composition. 

With  chronic  hydronephrosis  the  urine  may  be  cloudy 
from  mucus,  epithelial  cells,  and  leukocytes.  With  pyo- 
nephrosis the  urine  contains  pus,  often  in  considerable 
amounts.  If  the  opposite  kidney  is  healthy  and  the  ureter 
on  the  affected  side  becomes  obstructed  from  time  to  time, 
the  urine  during  such  periods  of  obstruction  is  clear,  but 
becomes  purulent  again  when  the  obstruction  is  relieved. 
The  pus  is  uniformly  mixed  with  the  urine.  In  hydro- 
nephrosis the  urine  is  acid  or  neutral;  in  pyonephrosis,  acid 
or  alkaline. 

The  ureteral  orifice  in  chronic  cases  of  hydronephrosis  is 
elongated  and  furrowed;  with  chronic  pyonephrosis  it  is 
usually  warped,  contracted  and  irregular,  or  elongated  and 
furrowed,  or  oval-shaped.  By  squeezing  the  kidney,  pus  may 
be  seen  to  emerge  from  the  ureteral  orifice.  In  the  acute 
cases  of  hydronephrosis  the  ureteral  orifice  is  not  changed ;  in 
acute  pyonephrosis  it  may  be  congested  or  scalded  or  eroded. 

The  efflux  during  the  period  of  obstruction  is  absent  on 
the  affected  side,  but  on  the  opposite  side  it  is  likely  to  be 
more  forcible.  With  pyonephrosis  the  efflux  is  muddy  and 
trickling  if  the  kidney  is  crippled,  or  a  solid  string  of  pus 
if  its  secretory  function  is  lost.  In  the  absence  of  a  tumor 
and  pain  in  the  affected  kidney  the  cystoscope  is  the  only 
means  by  which  we  can  ascertain  from  which  kidney  the  pus 
in  the  urine  is  derived. 

Pyonephrosis  is  readily  differentiated  from  hydronephrosis 
by  its  attendant  constitutional  symptoms,  by  the  pyuria, 


390     DISEASES  OF   THE  GENITOURINARY  ORGANS 

and  the  eroded  or  warped  or  irregular  ureteral  orifice.  Its 
differentiation  from  abscess  of  the  kidney  is  not  so  easy,  nor 
is  it  always  possible.  Intermittent  pyuria,  accompanied  by 
variations  in  the  size  of  the  tumor,  speaks  for  pyonephrosis. 
Pyuria,  constitutional  symptoms,  and  the  appearance  of  the 
ureteral  orifice  distinguish  pyonephrosis  from  all  other 
abdominal  tumors.^ 

An  acute,  small  hydronephrosis  may  from  its  stony  hard- 
ness resemble  a  carcinoma,  but  it  is  distinguished  from  this 
by  the  exquisite  pain  and  tenderness  that  accompany  it. 

Echinococcic  cysts  of  the  liver,  enlarged  gall-bladders, 
cysts  of  the  pancreas,  ovarian  cysts,  and  cysts  of  the  kidney 
must  be  differentiated  from  the  chronic  forms  of  hydro- 
nephrosis. In  the  first  place  the  history  or  physical  exami- 
nation affords  a  cause  for  the  hydronephrosis;  then,  again, 
the  tumor  occupies  the  loin  and  has  the  colon  in  front  and 
to  its  inner  side.  Cysts  of  the  liver  and  gall-bladder  have 
moderate  respiratory  mobility,  are  directly  connected  with 
the  liver,  and  lie  above  the  colon.  They  can  sometimes  be 
pushed  into  the  loin,  but  they  do  not  remain  there  when 
pressure  upon  them  is  relaxed.  With  gall-bladder  tumors 
there  is  a  history  of  attacks  of  biliary  colic,  with  or  without 
jaundice,  and  stones  in  the  stools.  With  echinococcic  cysts 
there  may  be  the  characteristic  fremitus. 

Pancreatic  cysts  are  retroperitoneal,  but  do  not  occupy 
the  loin;  they  lie  above  the  stomach,  or  between  it  and  the 
colon,  or  below  the  colon;  they  may  occasion  intermittent 
glycosuria  or  lipuria.  It  is  to  be  noted  that  large  pancreatic 
cysts,  like  other  large  abdominal  tumors,  may  by  pressure 
on  the  ureter  give  rise  to  hydronephrosis. 

Ovarian  cysts  with  elongated  pedicle  may  reach  up  into  the 
loin,  but  they  never  fully  occupy  it;  their  pedicle  can  be 
felt  per  vaginam;  they  are  freely  movable;  by  traction  upon 
the  uterus  the  tumor  is  pulled  downward;  they  are  further- 
more surrounded  by  tympanitic  coils  of  intestine,  thereby 
differing  from  hydronephrotic  tumors,  which  have  intestines 
only  to  the  inner  side. 

The  percentage  of  albuminuria  due  to  pus  can  be  estimated  by  counting  the 
leukocytes  ;  50,000  to  70,000  cells  correspond  to  L  per  cent,  of  albumin  by  the  Esbach 
test.    Rarely  does  albuminuria  from  this  cause  reach  above  1  per  cent. 


INFLAMMATIONS   OF    THE   KIDNEY  391 

It  is  to  be  especially  noted  that  in  chronic  hydronephrosis 
the  cystoscope  shows  the  ureteral  orifice  elongated  and 
furrowed,  whereas  in  all  the  other  conditions  above  mentioned 
the  ureteral  orifice  is  normal.  By  puncture  of  the  hydro- 
nephrotic  tumor  little  is  to  be  learned.  Its  contents  rarely 
contain  much  urea,  in  fact  no  more  than  may  be  found  in 
the  fluid  of  some  ovarian  cysts. 


RENAL  TUBERCULOSIS. 

Recent  clinical  experience  and  experimental  investigations 
would  go  to  show  that  tuberculosis  of  the  urinary  organs 
originates  in  the  kidneys ;  that  ascending  tuberculous  infection 
of  these  organs  is  most  improbable,  if  not  impossible,  and 
that  a  combined  infection  of  the  kidneys  and  genitals  must 
explain  the  combination  of  urinary  and  genital  tuberculosis. 
The  infection  of  the  urinary  organs  being  primary  in  the 
kidneys,  it  is  evident  that  the  earlier  the  affected  organ  is 
removed,  the  better  will  be  the  prognosis  for  radical  cure  of 
the  disease.  The  difficulty  lies  in  making  an  early  diagnosis 
of  such  renal  infection.  In  the  early  stages  there  are  very 
few  symptoms,  and  these  on  account  of  their  slightly  annoy- 
ing character  are  apt  to  escape  the  attention  of  the  patient 
and  his  physician.  After  a  shorter  or  longer  period  of  such 
latency,  however,  during  which  the  tuberculous  process  in 
the  kidney  is  constantly  progressing,  active  and  distressing 
symptoms  appear,  and  at  this  time  the  diagnosis  is  easy  and 
should  be  readily  made. 

The  earliest  manifestations  of  the  disease  come  from  the 
bladder,  which  the  tubercle-bacilli-laden  urine  irritates  and 
subsequently  infects.  The  early  vesical  symptoms  are  burn- 
ing pain  at  the  end  of  urination,  frequency  of  urination,  and 
inconstantly  cloudy  urine;  in  other  words,  symptoms  of  mild 
cystitis.  Every  case  presenting  such  symptoms,  that  is  not 
gonorrhoeal  in  origin  or  due  to  infection  by  instrumentation 
or  trauma,  should  be  suspected  of  being  tuberculous ;  in  them 
the  urine  should  be  repeatedly  and  carefully  examined  for 
tubercle  bacilli,  and  the  cystoscopic  appearances  of  the 
ureteral  orifice  and  vesical  mucosa  should  be  ascertained. 


392      DISEASES  OF  THE  GENITOURINARY  ORGANS 

(The  differentiation  of  tubercle  bacilli  from  smegma  bacilli 
is  made  by  drawing  the  urine  with  aseptic  catheter  and  by 
staining  methods.) 

During  the  early  stages  of  the  disease  there  are  not  any 
or  only  very  slight  constitutional  symptoms,  and  these  do 
not  point  to  the  kidney.  The  patients  may  feel  perfectly 
well  or  complain  of  lassitude,  or  of  being  easily  exhausted; 
they  may  be  pale  and  anaemic,  but  the  kidneys  are  not 
enlarged,  nor  sensitive,  nor  tender.  (Tuberculosis  in  other 
organs — the  lungs,  glands,  etc. — should  always  be  looked 
for,  as  its  presence  aids  us  in  making  the  diagnosis.) 

Cystoscopic  examination  in  the  early  stages  of  tubercu- 
lous disease  of  the  kidneys  may  reveal  no  changes  in  the 
bladder;  these  are  to  be  looked  for  especially  at  the  ureteral 
orifices.  The  first  manifestations  are  a  dilatation  of  the 
ureteral  orifice,  which  is  surrounded  by  reddened  mucous 
membrane.  A  little  later  a  few  sparsely  scattered  tubercles 
and  one  or  more  sharply  cut,  sloughing  ulcers  become  visible 
around  or  behind  the  ureteral  orifice.  The  efflux  is  cloudy, 
but  of  normal  force.  Gradually  the  rest  of  the  vesical 
mucosa  shows  evidences  of  tuberculous  infection,  in  the  shape 
of  red,  extravasated  areas  with  white,  necrotic  flakes  upon 
them,  or  superficial  erosions,  or  worm-eaten  ulcerations. 
These  ureteral  orificial  changes  are  very  characteristic  and 
should  prompt  frequent  and  repeated  examinations  of  the 
urine  for  tubercle  bacilli. 

As  the  tuberculosis  of  the  kidney  and  the  secondary  infec- 
tion of  the  bladder  advance,  the  vesical  and  kidney  symp- 
toms become  more  marked.  The  kidney  becomes  enlarged, 
tender,  and  painful;  tenesmus  and  frequency  of  urination  are 
distressing,  and  pyuria,  less  frequently  hsematuria,^  are  present. 
Hectic  fever,  night-sweats,  loss  of  weight,  anaemia,  and  loss  of 
appetite  are  the  constitutional  manifestations,  and  between 
the  fever  and  the  distressing  tenesmus  and  frequent  urination 
the  individual  is  most  wretched  and  miserable.  At  this  stage 
the  cystoscope  shows  the  ureteral  orifice  and  corresponding 
part  of  the  bladder-wall  dragged  out  of  the  normal  position, 
ulcerated,  patulous,  and  irregular,  together  with  ulcerations 

■  Painless  hsematuria  is  sometimes  the  very  first  evidence  of  renal  tuberculosis. 


INFLAMMATIONS  OF   THE   KIDNEY  393 

and  extravasations  on  other  parts  of  the  vesical  mucosa. 
At  times  the  ureteral  orifice  is  thickened,  irregular,  and  choked 
or  very  oedematous,  the  result  probably  of  a  very  acute  tuber- 
culous pyelitis.  At  this  period  the  efflux  is  a  puriform  trickle; 
the  urine  contains  many  tubercle  bacilli. 

Every  case  of  cystitis  that  is  not  gonorrhoeal  in  origin  or 
due  to  infection  by  instrumentation  and  trauma  is  to  be 
viewed  with  suspicion,  and  especially  so  in  women.  Cysto- 
scopic  examination  should  be  made  at  once  and  repeated 
from  time  to  time,  especial  attention  being  directed  to  the 
appearances  of  the  ureteral  orifices  and  the  character  of  the 
efflux.  The  urine  should  be  repeatedly  examined  for  tubercle 
bacilli,  for  which  purpose  several  quarts  of  urine  should  be 
sedimented  or  centrifuged.  If  the  urine  is  turbid  the  cysto- 
scope  will  enable  us  to  ascertain  from  which  kidney  the 
turbid  urine  descends,  a  knowledge  that  in  the  absence  of 
all  kidney  symptoms  is  of  the  utmost  importance  for  the 
localization  of  the  disease.  If  the  ureters  are  catheterized 
and  the  separated  urines  collected,  the  functional  activity  of 
each  organ  can  be  estimated,  without  which  determination 
no  extirpation  of  the  kidney  should  be  contemplated. 

Floating  and  movable  kidneys,  and  some  cases  of  renal 
calculus,  occasion  frequent  and  painful  urination  and  some- 
what cloudy  urine.  The  differentiation  of  the  early  stages 
of  tuberculosis  of  the  kidney  from  these  conditions  is  attended 
with  difficulty,  and  especially  so  if  a  tuberculous  infection  has 
been  engrafted  upon  a  movable  or  calculus-containing  kidney, 
an  occurrence  that  is  by  no  means  infrequent  or  rare.  The 
cystoscopic  appearance  of  the  ureteral  orifice  and  the  pres- 
ence of  tubercle  bacilli  in  the  urine  will  have  to  be  relied 
on  to  establish  the  differential  diagnosis,  or  the  combined 
affection. 

The  later  stages  of  tuberculous  kidney  disease  may  without 
the  cystoscope  be  confused  with  suppurative  nephritis,  with 
which  a  tuberculosis  may  also  be  combined.  The  cysto- 
scopic appearance  of  the  ureteral  orifices  and  of  the  vesical 
mucosa  and  the  presence  of  tubercle  bacilli  in  the  urine  will 
serve  to  differentiate  the  two  affections  when  they  are  singly 
present,  while  a  rapid  course  of  the  disease,  with  numerous 
pyogenic  bacteria  in  the  urine,  will  point  to  a  mixed  or  com- 


394     DISEASES  OF   THE  GENITOURINARY  ORGANS 

bined  infection.     Secretory  death  of  the  kidney  is  indicated 
by  an  efflux  of  soHd  pus  from  the  ureter. 

If  calculus  disease  has  been  the  primary  affection  the 
history  would  very  likely  afford  the  information  of  repeated 
kidney  colics  and  hsematuria,  the  x-ray  would  show  the 
presence  of  calculi,  and  the  cystoscopic  picture  of  the  ureteral 
orifices  and  the  presence  of  tubercle  bacilli  in  the  urine 
would  indicate  the  existence  of  a  tuberculous  infection.  The 
secondary  formation  of  calculi  in  a  tuberculous  kidney  is  only 
to  be  recognized  from  the  passage  of  small  calculi,  and  by 
a:-ray  examination. 


PLATE   IV. 


Aseptic  Renal  Stone. 


CHAPTER   XXXVIII. 

RENAL  STONE. 

Until  the  introduction  of  the  Roentgen  ray  our  diagnosis 
of  those  aseptic  renal  stones  that  provoke  only  pain  in  the  loin 
and  hypochondrium  was  always  uncertain,  for  there  were 
no  physical  findings  to  direct  us  to  the  seat  and  cause  of  the 
suffering.  In  some  of  these  cases  we  were  able  by  a  process 
of  exclusion  after  long-continued  observation  of  the  patient, 
and  after  careful  analysis  of  the  gastric  secretion,  to  rule  out 
gastric  and  biliary  affections  as  a  cause  of  the  symptoms; 
in  some  we  were  able  to  narrow  down  the  possibilities  to 
some  affection  of  the  kidney,  but  further  than  this  we  could 
not  with  any  degree  of  certainty  go.  Nor  did  the  occurrence 
of  even  repeated  attacks  of  kidney  colic  with  hsematuria  help 
us  to  a  positive  diagnosis  of  kidney  stone,  for  in  many  of  such 
cases  in  which  we  were  led  by  these  symptoms  to  expose  and 
incise  the  kidney  with  the  almost  certain  expectation  of 
finding  a  stone,  we  were  surprised  to  find  no  stone,  but  some- 
times a  chronic  nephritis  and  again  only  perinephritic  adhe- 
sions. A  most  carefully  conducted  urinary  examination  did 
not  help  us  to  differentiate  these  conditions,  though  the 
continued  presence  of  crystals  of  uric  acid  or  oxalate  of  lime 
strongly  suggested  a  calculus,  just  as  a  preceding  infection 
of  the  kidney  during  an  acute  infectious  disease  or  otherwise 
suggested  a  chronic  nephritis  or  perinephritic  adhesions. 

With  the  introduction  of  the  a;-ray,  however,  this  difficulty 
has  to  a  large  extent  disappeared,  for  it  is  the  author's  expe- 
rience that  an  expert  radiographist  will  seldom,  if  ever,  fail 
to  find  an  oxalate  renal  stone,  and  in  most  instances  he  will 
be  able  to  obtain  a  shadow  of  a  uric  acid  stone. ^     He  may 

1  In  very  stout  individuals  tlie  results  of  x-ray  photography  for  renal  calculi  are  not 
as  satisfactory  as  they  are  in  thin  subjects.  Due  allowance  must  he  made  in  such 
obese  patients  in  forming  our  conclusions  as  to  the  presence  or  absence  of  a  renal 
stone  from  the  x-ray  photograph. 


396     DISEASES  OF   THE  GENITOURINARY  ORGANS 

have  to  take  a  number  of  exposures,  but  if  he  persists,  he 
will  be  able  to  locate  the  stone  if  it  is  present. 

When  the  stone  commences  to  travel  down  the  ureter  the 
diagnosis  becomes  very  much  easier,  for  in  addition  to  the 
kidney  colic  and  hsematuria,  the  passage  of  the  stone  through 
the  lower  portion  of  the  ureter  is  attended  with  typical 
changes  in  the  appearances  of  the  vesical  orifice  of  the  ureter. 
(See  p.  375.)  Similarly  when  the  stone  becomes  impacted 
in  the  lower  third  of  the  ureter  there  are  characteristic 
changes  in  the  vesical  ureteral  orifice.  An  acute  hydro- 
nephrosis, indicated  by  exquisite  pain,  swelling  and  stony 
hardness  of  the  kidney,  following  an  attack  of  kidney  colic 
with  hsematuria  is  strong  evidence  of  an  impacted  stone  in 
the  ureter,  just  as  is  a  complete  anuria  after  a  kidney  colic. 
Complete  anuria  does  not  always  signify  that  both  ureters 
are  obstructed  by  calculi,  for  it  also  occurs  when  only  one  of 
the  ureters  is  obstructed,  the  function  of  the  remaining 
kidney  being  reflexly  suspended.  As  in  these  latter  cases  in- 
cision of  the  obstructed  kidney  alone  usually  suffices  to  relieve 
the  anuria,  it  is  a  matter  of  the  utmost  importance  to  ascer- 
tain which  is  the  obstructed  kidney.  This  can  be  done  only 
by  the  ureteral  catheter;  it  is  not  safe  to  rely  on  the  location 
of  the  pain  for  this  determination,  for  in  many  instances  of 
unilateral  renal  stone  the  patients  complain  of  pain  in  the 
opposite  healthy  organ.  The  ureteral  catheter  informs  us 
not  only  of  the  presence  of  an  obstruction,  but  also  of  its 
site,  a  most  important  point  when  operative  interference  for 
its  removal  is  to  be  undertaken. 

When  a  kidney  that  is  the  seat  of  a  stone  becomes  infected 
and  in  virtue  of  such  infection  a  pyelitis  or  a  pyonephrosis 
or  suppurative  nephritis  develops,  the  evidences  afforded  by 
the  latter  conditions  are  usually  clear  enough  to  render  their 
recognition  easy.  It  is  not  always  so  simple,  however,  to 
ascertain  that  they  are  primarily  due  to  a  stone.  A  history 
of  attacks  of  renal  colic  and  hsematuria  is  very  suggestive  of 
their  connection  with  renal  calculus. 

The  pain  in  renal  colic  is  sharp  and  cutting  in  character, 
commencing  in  the  loin  and  radiating  down  into  the  genitals 
and  thigh.  It  resembles  in  its  character  that  which  is  due 
to  biliary  colic,  and  gastric  or  duodenal  ulcer.     Renal  colic, 


RENAL  STONE  397 

however,  is  usually  attended  with  hsematuria;  as  this  hsema- 
turia  may  be  only  microscopic,  it  is  of  the  highest  importance 
to  carefully  examine  the  urine  in  all  cases  for  the  presence  of 
red  blood  cells.  In  biliary  colic  the  pain  starts  in  the  right 
hypochondrium  and  radiates  to  the  back  and  right  shoulder. 
The  pain  due  to  gastric  ulcer  is  usually  accompanied  by 
other  evidences  of  this  malady — viz.,  vomiting,  hyperacidity, 
hsematemesis,  or  melsena.  The  pain  in  duodenal  ulcer  is  most 
severe  two  or  three  hours  after  a  meal,  but  the  differentiation 
of  the  two  conditions  without  the  a:-ray  is  sometimes  exceed- 
ingly difficult.  The  plan  suggested  by  Kelly  to  demonstrate 
the  presence  of  a  stone  in  the  ureter  or  kidney  pelvis — viz., 
to  pass  a  waxed-tipped  catheter  into  the  ureter  and  see 
whether  the  wax  is  scratched — is  of  much  less  diagnostic 
value  than  is  the  Roentgen-ray  examination. 


CHAPTER  XXXIX. 

NEOPLASMS  OF  THE  KIDNEY. 

The  clinically  important  kidney  tumors  are  chiefly  met 
with  during  two  periods  of  life — before  puberty  (in  some 
cases  very  shortly  after  birth)  and  after  the  fortieth  year. 
Benign  tumors,  as  lipoma,  fibroma,  adenoma,  and  chon- 
droma, are  of  infrequent  occurrence;  malign  tumors,  as 
carcinoma  and  sarcoma,  are  relatively  frequent ;  and  hyper- 
nephroma, simple  cysts,  polycystic  degeneration,  and  echino- 
coccic  cysts  less  so. 

The  best  clinical  evidence  of  a  neoplasm  is  the  presence 
of  a  palpable  tumor.  Should  the  tumor  be  located  at  the 
upper  pole  or  on  the  posterior  surface  of  the  organ,  its  detec- 
tion by  palpation  would  be  long  delayed,  unless  the  patient  is 
thin  and  the  kidney  movable.  Malignant  tumors  are  usually 
hard  with  irregular  nodular  surface,  whereas  benign  growths 
and  cysts  have  a  smooth  surface. 

Other  clinical  evidences  of  a  neoplasm  are  renal  pain  and 
hsematuria.  These  are  usually  present  before  a  tumor  can 
be  palpated.  The  pain  is  due  either  to  distention  of  the 
kidney  pelvis  with  blood,  in  which  case  it  is  colicky  in 
character,  or  it  is  due  to  the  neoplasm  itself,  in  which  case 
it  is  a  continuous  dull  ache.  The  hsematuria  varies  in  the 
severity  and  constancy  of  its  occurrence.  With  benign 
growths  and  some  malignant  ones,  it  never  occurs;  again, 
in  some  cases  it  is  very  slight  in  amount,  and  unless  accom- 
panied by  pain  it  is  not  apt  to  attract  the  patient's  attention. 
In  other  cases  it  is  very  profuse  and  lasts  several  days,  and 
is  accompanied  by  severe  colicky  pain. 

The  urine  at  the  times  of  bleeding  is  bright  red  or  smoky 
in  color,  and  at  times  contains  ureteral  and  urethral  blood 
clots.  Israel  considers  that  old,  decolorized  casts  passed  with 
clear  urine  undoubtedly  come  from  the  ureter,  and  that  soft, 


NEOPLASMS  OF   THE   KIDNEY  399 

white  or  light  yellow  or  red,  earthworm-like  clots  are  char- 
acteristic of  kidney  tumor.  Under  the  microscope  numerous 
red  and  white  blood  cells,  fat  droplets,  casts,  and  epithelia 
of  all  kinds  are  to  be  seen. 

Antemia,  cachexia,  and  emaciation  are  late  evidences  of 
kidney  tumors.  Guyon  lays  stress  on  the  occurrence  of 
varicocele  with  neoplasms  of  the  kidney. 

Benign  Tumors. — Benign  tumors  are  of  little  clinical 
importance;  they  rarely  attain  large  size  and  do  not  give  rise 
to  any  symptoms. 

Malignant  Growths. — Malignant  growths  are  quite  com- 
mon. The  carcinomata  form  nodular  or  smooth  infiltrating 
tumors  of  hard  or  soft  consistency,  which,  as  a  rule,  can  be 
palpated,  and  are  accompanied  by  renal  pain  and  hsematuria. 
The  sarcomata,  endotheliomata  and  embryonal  sarcomata  of 
children  exhibit  the  usual  characteristics  of  malignant  tumors, 
though  the  bleeding  may  not  be  marked.  Embryonal  sarco- 
mata occur  during  the  first  two  years  of  life,  though  they 
have  been  met  with  as  late  as  the  fourteenth  year.  They 
grow  very  fast,  rarely  give  rise  to  heematuria,  and  are  not 
very  likely  to  occasion  metastases.  In  almost  every  one 
of  these  particulars  they  differ  from  the  hypernephromata 
(tumors  of  aberrant  adrenal  tissue  in  the  kidney).  These 
latter  are  almost  invariably  encountered  after  the  thirtieth 
year  of  life,  grow  slowly,  and  are  attended  with  marked  and 
profuse  hsematuria,  which  is,  as  a  rule,  the  first  indication  of 
their  presence. 

Cystic  Tumors. — Of  cystic  tumors  there  may  be  single 
cysts,  or  echinococcus  cysts,  or  the  entire  organ  may  be  the 
seat  of  polycystic  degeneration.  The  last  mentioned  may 
be  congenital  in  origin  or  develop  in  later  life;  it  is  usually 
bilateral.  Many  of  the  infants  affected  with  bilateral  cystic 
degeneration  of  the  kidneys  are  not  viable;  their  kidneys 
are  represented  by  large  tumors  with  nodular  surface,  which 
it  is  scarcely  possible  to  differentiate  from  solid  growths. 
The  acquired  polycystic  degeneration  is  often  combined  with 
cysts  of  the  liver;  it  is  likewise  bilateral  in  the  majority  of 
the  cases.  As  the  hsematuria,  colicky  pain,  and  tumor  which 
result  from  this  disease  also  accompany  other  neoplasms  of 
the  kidney,  it  is  not  always  possible  to  make  the  diagnosis. 


400     DISEASES  OF    THE  GENITOURINARY  ORGANS 

In  favor  of  polycystic  degeneration  are  the  following  facts: 
A  history  of  other  members  of  the  family  having  suffered 
from  the  same  affection,  a  slow  growth  of  the  tumor,  and  an 
absence  of  cachexia  and  of  all  data  pointing  to  tuberculosis 
or  suppuration  of  the  kidney.  Probatory  puncture  through 
the  loin  will  differentiate  a  polycystic  kidney  from  a  hydro- 
nephrotic  sac,  for  by  puncture  we  empty  only  one  of  the 
cysts  and  the  tumor  consequently  remains,  whereas  hydro- 
nephrotic  sacs  are  entirely  evacuated  by  puncture,  with  dis- 
appearance of  the  tumor.  The  bilateral  character  of  the 
disease  may  be  recognized  from  the  symptoms  of  contracted 
kidney  with  cardiac  hypertrophy.  Bilateral  disease,  accom- 
panied by  cysts  of  the  liver,  and  the  symptoms  of  con- 
tracted kidney  and  cardiac  hypertrophy  make  the  diagnosis 
positive. 

Single  cysts  of  the  kidney  are  not  common.  They  vary  in 
size,  and  may  grow  to  the  size  of  an  adult  head.  They  have 
been  noticed  between  the  eighteenth  and  sixty-fifth  years  of 
life. 

Echinococcic  cysts  are  first  noticed  when  they  reach  a 
large  size;  they  grow  slowly,  form  smooth,  rounded  tumors, 
and  do  not  occasion  any  material  symptoms.  If  they  per- 
forate into  the  ureter  so  that  daughter-cysts  are  passed  with 
the  urine  (always  with  an  attack  of  kidney  colic),  the  diag- 
nosis is  clear,  otherwise  this  will  remain  doubtful  until  the 
tumor  is  exposed  on  the  operating  table. 

Adrenal  Tumors. — Adrenal  tumors,  which  are  most  fre- 
quently of  a  tuberculous  nature,  cannot  be  palpated  unless 
they  reach  a  large  size,  and  at  this  time  their  differentiation 
from  kidney  tumors  is  very  difficult.  Clinically  they  are 
distinguished  from  renal  neoplasms  by  the  fact  that  they  do 
not  frequently  occasion  hsematuria.  The  chief  symptoms  to 
which  they  give  rise  result  from  compression  of  the  lumbar 
nerves  and  vena  cava  inferior — viz.,  pain  in  the  area  of 
distribution  of  these  nerves,  ascites  and  oedema  of  the  legs. 
Bronzing  of  the  skin  and  mucous  membranes,  which  fre- 
quently accompanies  adrenal  disease,  is  likely  to  be  absent 
with  neoplasms  of  this  organ. 


CHAPTER   XL. 

DISEASES  OF  THE  URETER. 

Accidental  trauma  rarely  results  in  injuries  of  the  ureter 
alone;  it  generally  occasions  wounds  of  other  viscera  as  well, 
and  the  evidences  of  these  mask  the  symptoms  which  come 
from  the  injured  ureter.  The  usual  sequela  of  a  torn  or 
crushed  ureter  is  the  formation  of  a  retroperitoneal  tumor; 
this  is  tender  and  painful  and  yields,  on  aspiration,  urine  or 
urine  mixed  with  a  little  blood. 

Accidental  injuries  of  the  ureter  during  pelvic  and  abdom- 
inal operations  are  recognized  from  the  profuse  secretions 
from  the  wound  immediately  after  operation,  and  from  the 
diminished  amount  of  urine,  possibly  bloody  in  character, 
which  is  voided  from  the  bladder.  Intraperitoneal  injuries 
with  consequent  escape  of  urine  into  the  peritoneal  cavity  are 
recognized  only  after  the  abdomen  has  been  opened  for  treat- 
ment of  the  septic  peritonitis  to  which  the  lesion  gives  rise. 

The  inflammations  of  the  ureter  are  usually  secondary  to 
those  of  the  kidney  and  bladder,  and  are  recognized  from  the 
thickening  of  the  tube  and  the  pain  and  tenderness  along  its 
course.  The  thickening  can  be  appreciated  by  abdominal, 
by  rectal,  and  by  vaginal  palpation.  Inflammation  of  the 
right  ureter  has  been  mistaken  for  disease  of  the  appendix, 
but  the  presence  of  vesical  or  kidney  disease  and  the  absence 
of  a  typical  history  of  appendicitis  should  enable  us  to  readily 
differentiate  the  two.  Sometimes  appendicular  or  other 
abscesses  perforate  into  the  ureter,  and  so  occasion  vesical 
tenesmus  and  pyuria.  This  condition  will  be  understood  if 
we  find  from  the  history  and  from  examination  that  an 
abscess  was  present  prior  to  the  onset  of  the  vesical  tenesmus 
and  pyuria.  The  cystoscope  will  distinguish  perforations  of 
abscess  into  the  bladder  from  those  into  the  ureter;  with  the 
former  we  ought  to  be  able  to  see  the  site  of  perforation. 

26 


402     DISEASES  OF   THE  GENITOURINARY  ORGANS 

Kinks,  strictures,  and  valve  formation  are  to  be  recognized 
from  the  hydronephrosis  which  they  occasion  and  from  the 
obstruction  such  conditions  afford  to  the  passage  of  the 
ureteral  catheter/ 

Neoplasms  are  very  rare,  but  papilloma,  sarcoma,  and 
carcinoma  have  been  reported.  They  obstruct  the  ureteral 
channel,  cause  a  hydronephrosis,  and  occasion  hsematuria, 
from  which  signs  their  presence  may  with  considerable 
reservation  be  assumed. 

1  Incomplete  obstruction  of  the  ureter  by  stricture  or  kink  is  evidenced  by  dull  pain 
along  the  course  of  the  ureter  and  by  frequent  urination.  The  diagnosis  can  only  be 
made  by  the  ureteral  catheter. 


CHAPTER   XLL 
DISEASES   AND  INJURIES  OF  THE   URINARY  BLADDER. 

A  SOMEWHAT  similar  symptom  complex  attends  most  of 
the  diseases  of  the  urinary  bladder,  and  by  its  close  study 
we  will  be  able,  as  a  rule,  to  differentiate  the  disorders  of 
this  organ  from  those  of  the  rest  of  the  urinary  apparatus. 
But,  though  it  is  possible  from  the  physical  sufferings  of  the 
patient  to  locate  the  seat  of  the  urinary  malady  in  the  bladder, 
it  is  not  usually  possible  to  learn  the  precise  nature  of  the 
affection  in  this  way.  To  ascertain  this  we  must  palpate,^ 
percuss,  cystoscope,  and  sound  the  bladder,  estimate  its 
capacity,  and  find  out  whether  it  empties  itself  at  each  act 
of  urination. 

The  complaints  that  direct  our  attention  to  the  urinary 
bladder  are  pain,  tenesmus,  and  increased  frequency  of 
urination.  Changes  in  the  force,  calibre,  and  character  of  the 
urinary  stream  are  sometimes  in  evidence,  pyuria  only  with 
the  inflammatory  and  ulcerative  diseases,  and  hsematuria 
with  the  inflammatory,  ulcerative,  neoplastic,  and  calculous 
diseases  of  the  viscus. 

In  vesical  disease  a  dull  ache  or  pain  may  be  continuously 
present  in  the  hypogastric  or  perineal  regions.  It  is  usually 
severe  at  the  beginning  of  and  throughout  urination,  and 
when  the  vesical  orifice  is  involved  it  is  especially  acute  at 
the  end  of  the  act.  In  the  latter  instance  it  is  referred  to  the 
glans  penis. 

Tenesmus  is  especially  marked  in  the  inflammatory  dis- 
eases. The  patient  may  have  to  pass  water  every  few 
minutes,  and  that  with  great  pain  and  straining.  The  pain 
is  most  severe  just  before  and  at  the  end  of  urination. 

1  In  palpating  the  bladder,  we  should  not  forget  to  avail  ourselves  of  bimanual 
palpation,  the  finger  of  the  one  examining  hand  being  introduced  into  the  rectum  or 


404     DISEASES  OF   THE    GENITOURINARY  ORGANS 

The  frequency  of  urination  depends  on  the  nature  of  the 
malady,  its  location,  the  size  of  the  bladder,  and  upon  whether 
the  viscus  empties  itself  at  each  act  of  urination.  In  inflam- 
matory and  ulcerative  diseases,  especially  if  they  involve  the 
vesical  neck,  there  is  a  desire  to  pass  water  every  few  minutes ; 
with  neoplasm  and  stone,  not  complicated  by  cystitis,  the 
frequency  is  not  much  altered;  and  in  cases  of  partial  reten- 
tion or  with  a  contracted  bladder  the  frequency  depends  upon 
the  amount  of  residual  urine  and  the  capacity  of  the  organ. 

Pyuria  occurs  only  with  the  inflammatory  and  ulcerative 
diseases.  Vesical  pyuria  is  readily  difl^erentiated  from  renal 
pyuria  by  the  following  procedure:  the  bladder  is  washed 
until  the  water  returns  clean;  if  now  the  bladder  is  filled  with 
clean  water,  this  will  become  rapidly  turbid  if  the  pus 
descends  from  the  kidneys,  and  remain  clean  for  a  much 
longer  time  if  the  pus  is  vesical  in  its  origin.  Vesical  pyuria 
is  to  be  differentiated  from  urethral  pyuria  by  making  the 
patient  urinate  into  three  glasses.  The  first  couple  of  ounces, 
which  wash  out  the  urethra,  are  passed  into  one  beaker,  and 
the  rest  into  two  other  beakers.  If  the  first  urine  is  turbid, 
whereas  the  second  and  third  are  clear,  the  pus  comes  from  the 
anterior  urethra;  if  all  are  cloudy  it  comes  from  the  bladder; 
if  the  first  is  most  turbid,  the  second  less  so,  and  the  third  still 
less,  the  pus  is  derived  from  the  posterior  urethra;  if  the 
first  and  second  are  cloudy  and  the  last  most  so,  the  pus  is 
derived  from  the  bladder  and  trigonum. 

Cloudiness  of  the  urine  is  not  to  be  interpreted  in  every 
case  as  due  to  pus.  It  may  be  caused  by  uric  acid,  phos- 
phates, oxalates,  fat,  chyle,  or  bacteria.  If  it  is  due  to  uric 
acid  it  is  dispelled  by  heat;  if  it  is  due  to  phosphates  it 
disappears  on  the  addition  of  acetic  acid,  and  if  it  is  caused 
by  oxalates  it  is  cleared  up  by  adding  hydrochloric  acid. 
If  these  tests  do  not  succeed  in  clearing  up  the  urine,  and 
potassium  hydrate  is  now  added  to  it,  a  gelatinous  trans- 
parency will  take  the  place  of  the  turbidity  if  it  is  due  to  pus 
(Donne's  test).  If  this  test  fails  we  may  assume  that  the 
cloudiness  is  due  to  bacteria,  and  their  presence  is  then 
to  be  verified  by  microscopic  examination.  Cloudiness  of 
the  urine  due  to  fat  is  dispelled  by  the  addition  of  alcohol 
ether. 


DISEASES  AND   INJURIES  OF   URINARY  BLADDER     405 

With  the  inflammatory  and  ulcerative  diseases  of  the 
bladder,  the  urine  is  usually  alkaline  in  reaction.  The 
ammonia  which  is  set  free  by  the  alkaline  decomposition  of 
the  urine  reacts  upon  the  pus  and  changes  it  into  a  ropy, 
reddish  sediment,  which  adheres  to  the  vessel  into  which 
the  urine  is  passed. 

Abundant  epithelial  cells  are  present  in  the  urine  of  those 
suffering  with  vesical  disease,  but  it  is  not  possible  to  state 
from  the  shape  and  character  of  the  epithelia  what  their 
source  is.  The  presence  of  fragments  of  papillary  or  malig- 
nant tumors  in  the  urine  usually  points  to  such  disease  of 
this  organ. 

Hcematiiria  occurs  in  greater  or  less  amount  and  at  some 
time  or  other  with  most  of  the  vesical  diseases.  The  blood 
is  uniformly  distributed  in  the  urine,  and  the  clots  are 
rounded.  Vesical  hsematuria  is  to  be  differentiated  from 
renal  hsematuria  only  by  the  aid  of  the  cystoscope,  and  from 
urethral  hematuria  by  cystoscopy  and  endoscopy. 

While  the  symptoms  just  detailed  point  to  vesical  disease, 
the  nature  of  the  latter  can  only  be  ascertained  by  physical 
examination,  cystoscopy,  and  sounding.  A  hint  as  to  its 
character  may  sometimes  be  gleaned  from  the  history. 
Thus  with  stone  and  pedunculated  tumors  the  patient 
experiences  sudden  stoppage  of  the  urinary  stream,  which 
a  change  in  his  position  may  prevent,  and  which  a  certain 
posture  during  the  act  of  urination  may  avoid.  Again, 
patients  with  stone  in  the  bladder,  and  especially  the  children 
who  are  thus  afflicted,  are  noticed  to  pull  on  the  penis  and 
frequently  masturbate,  and  their  straining  to  overcome  the 
sudden  impediment  to  urination  leads  to  prolapsus  ani  and 
hernia.^  With  cystitis  the  tenesmus  is  especially  marked  and 
the  urine  is  usually  turbid  and  alkaline.  With  neoplasm  the 
first  symptom  is  very  often  "hsematuria."  Such  data  suggest 
the  diagnosis,  which  can  then  be  confirmed  with  the  cystoscope 
and  searcher.  In  acute  diseases,  however,  the  use  of  these 
instruments  is  attended  with  so  much  pain,  and  the  possi- 
bility of  aggravating  the  malady  by  their  use  is  so  great,  that 

'  It  is  worth  while  to  examine  children,  who  have  an  acquired  hernia  from  no 
accountable  cause,  for  vesical  calculus. 


406     DISEASES  OF   THE  GENITOURINARY  ORGANS 

it  is  preferable  to  rely  upon  the  symptoms  for  making  a  diag- 
nosis during  the  early  stages. 

In  contracted  bladder  due  to  tuberculosis  cystoscopy  is 
likewise  not  well  borne,  and  if  the  diagnosis  can  be  made 
without  its  aid,  the  patient  will  be  spared  much  pain  and 
possibly  an  exacerbation  of  the  malady. 

If  there  is  much  bleeding  from  the  bladder,  cystoscopy  will 
usually  be  impossible.  The  lesser  degrees  can  be  overcome 
by  irrigating  the  bladder  with  1  to  10,000  adrenalin  solution 
or  by  using  the  Nitze  irrigation  cystoscope. 


CYSTOSCOPIC  APPEARANCES  IN  DISEASES  OF  THE 
BLADDER. 

Cystitis. — In  acute  cystitis  the  mucous  membrane,  espe- 
cially that  of  the  trigonum  and  vesical  neck,  is  deeply 
injected,  swollen,  of  intense  red  color,  and  almost  velvety 
in  appearance.  Flakes  of  mucus  and  pus  are  visible  on 
its  surface. 

In  chronic  cystitis  the  mucous  membrane  appears  swollen, 
somewhat  thickened  and  congested,  is  covered  with  patches 
of  grayish-yellow  pus  and  mucus,  and  is  studded  with  ecchy- 
motic  areas;  sometimes  there  are  to  be  seen  ulcerations  of 
varying  size  and  depth,  and  occasionally  there  are  pseudo- 
vesicles  in  the  oedematous  mucous  membrane  or  polypus- 
like proliferations  in  the  mucosa.  These  evidences  are  most 
marked  at  the  trigonum,  which  is  of  a  dark-red  color,  swol- 
len, and  raised  into  numerous  thickened  folds.  In  cases  of 
cystitis  secondary  to  conditions  which  interfere  with  the 
free  passage  of  urine  from  the  bladder — e.  g.,  urethral  stric- 
tures, hypertrophy  of  the  prostate,  etc. — there  are  prom- 
inent ridges  and  trabeculse  on  the  interior  of  the  vesical  wall 
from  thickening  of  the  muscular  coat,  and  between  them 
the  mucous  membrane  is  pouched  out  into  diverticula  and 
sacculations  which  sometimes  contain  secondary  phosphatic 
calculi. 

Tuberculosis. — If  the  vesical  affection  is  secondary  to 
a  kidney  tuberculosis,^ the  lesions  are  most  marked  around 
the  ureteral  orifices;  on  the  other  hand,  when  it  is  second- 


PLATE  V. 


D. 


A.  Villous  tumor  of  the  bladder. 

B.  Cancerous  tumor  of  the  bladder. 

C.  Uric  acid  stone.    ■ 

D.  Congenital   diverticulum. 

Note  absence  of  trabeculation  of  bladder  wall  in  D,  which  differentiates  a  congenital  diver- 
ticulum from  an  acquired  diverticulum.     (From  Nitze.) 


PLATE  VI. 


Large  Vesical  Stone. 


DISEASES  AND  INJURIES  OF   URINARY  BLADDER     407 

ary  to  genital  tuberculosis  the  lesions  are  diffused  over  the 
whole  bladder  wall.  For  the  description  of  the  lesions 
around  the  ureteral  orifices,  see  p.  374.  On  the  rest  of 
the  vesical  mucosa  in  the  early  stages  of  the  disease  are  red 
extravasated  areas  with  white  necrotic  flakes  on  them  or 
grayish- white  tubercles,  or  superficial  erosions  or  worm- 
eaten  ulcerations.  In  more  advanced  stages  of  the  disease 
the  bladder  is  contracted  and  trabeculated,  the  mucous 
membrane  is  thickened  and  covered  with  thick  pus  and 
mucus  and  is  studded  with  worm-eaten  ulcerations,  red 
areas  of  extravasation,  and  groups  of  grayish-white  tubercles. 

Papillomata. — Papillomata  appear  as  shaggy,  papillary, 
pedunculated,  or  sessile,  single  or  multiple  tumors,  gen- 
erally situated  at  the  ureteral  orifices  or  fundus  of  the 
bladder. 

Carcinomata.—Carcinomata  appear  as  shaggy,  infiltrating, 
thickened  tumors,  or  as  flattened  infiltrations  or  as  everted, 
irregular,  easily  bleeding  ulcerations. 

Calculi. — Calculi  are  readily  recognized,  and  their  shape, 
size,  color,  and  number  easily  determined. 

The  presence  or  absence  of  stone  may  also  be  determined 
by  the  searcher  and  a;-ray  examination.  By  palpation  of  the 
base  of  the  bladder  through  the  rectum  the  presence  of  a 
neoplasm  and  occasionally  that  of  calculi  can  be  determined, 
and  by  bimanual  palpation  through  the  rectum  and  over  the 
hypogastric  region  the  presence  of  mural  neoplasms  or 
abscesses,  or  of  large  calculi  may  at  times  be  detected. 

By  percussion  and  palpation  over  the  hypogastrium  the 
oval,  fluid-containing  (fluctuating)  dull  tumor  representing 
a  distended  bladder  can  be  detected.  Digital  examination  of 
the  interior  of  the  bladder  in  the  female  after  dilating  the 
urethra  is  rarely  resorted  to  for  diagnostic  purposes. 

The  examination  for  tubercle  bacilli  should  be  made  in 
all  suspected  cases  of  tuberculosis;  in  this  connection  it  is 
to  be  especially  noted  that  cases  of  chronic  cystitis  for  which 
no  etiological  cause  can  be  ascertained  and  which  are 
rebellious  to  local  treatment  are  very  likely  tuberculous 
in  character,  and  careful  examination  of  the  urogenital 
system,  especially  the  kidneys  and  testicles,  is  to  be  made 
for  primary  foci  of  this  disease. 


408     DISEASES  OF   THE  GENITOURINARY  ORGANS 

INJURIES  OF  THE  BLADDER. 

The  history  of  an  injury^  over  the  hypogastric  region,  and 
especially  if  such  injury  has  caused  a  fracture  of  the  pelvis, 
together  with  difficulty  in  urination,  tenesmus,  and  bloody 
urine,  is  very  suggestive  of  an  injury  to  the  bladder  or 
urethra.  A  rupture  of  the  bladder  may  be  assumed  if  cathe- 
terism  is  easy  and  if  very  little  bloody  urine  is  found  in  the 
bladder.  The  assumption  can  be  verified  by  injecting  a 
measured  quantity  of  fluid  into  the  bladder  and  then  measur- 
ing the  amount  that  returns  through  the  catheter.  With 
a  bladder  rupture  the  return  amount  does  not  correspond 
with  the  amount  which  has  been  injected.  Bleeding  from 
the  urethra  independent  of  urination  suggests  a  rupture  or 
injury  of  the  urethra,  in  which  case  the  passage  of  the 
catheter  is  likely  to  be  obstructed. 

It  is  not  always  possible  to  tell  at  the  outset  whether  the 
site  of  the  rupture  in  the  bladder  is  on  its  peritoneal  or  extra- 
peritoneal surface.  But  if  the  rent  is  not  at  once  repaired 
the  subsequent  developments  will  reveal  its  site;  for  with 
intra-peritoneal  rupture  there  develops  sooner  or  later, 
depending  on  the  aseptic  or  septic  condition  of  the  urine, 
a  diffuse  septic  peritonitis,  and  with  extraperitoneal  rupture 
there  develops  a  gangrenous,  phlegmonous  inflammation  of 
the  cellular  tissues  in  front  and  at  the  base  of  the  bladder. 

1  It  is  to  be  noted  that  the  patient  may  have  been  under  the  influence  of  alcohol  or 
other  narcotic  when  the  injury  was  sustained  and  consequently  is  not  conscious  of 
it,  and  also  that  in  distended  conditions  of  the  bladder  a  very  slight  traumatism  that 
ordinarily  is  not  severe  enough  to  make  an  impression  upon  the  individual  may 
result  in  a  rupture  of  this  viscus. 


CHAPTER   XLII. 
URINARY  FISTUL.E:    DISTURBANCES  OF  MICTURITION. 

Fistulae  connected  with  the  urinary  organs  are  readily 
recognized  from  the  urinous  fluid  which  they  discharge. 
The  internal  orifice  may  be  located  in  the  kidney,  ureter, 
bladder  or  urethra,  and  the  external  opening  in  the  loin,  on 
the  abdominal  wall,  the  external  genitals,  in  the  uterus  or 
vagina,  in  the  rectum  or  on  the  thighs.^ 

In  every  case  of  such  fistula  it  is  essential  to  locate  the 
internal  and  the  external  openings.  If  the  internal  orifice 
is  situated  in  the  kidney,  in  the  ureter  or  in  the  bladder, 
there  is  a  constant  dribbling  of  urine  from  the  external 
opening,  whereas  if  it  is  situated  in  the  urethra  there  is  a 
leakage  of  urine  only  during  urination,  unless  the  patient  is 
incontinent  from  other  causes.  To  differentiate  the  ureteral 
from  the  vesical  fistulae,  we  fill  the  bladder  with  colored  fluid 
and  watch  the  external  opening  of  the  fistula.  If  the  fistula 
is  a  vesical  one  the  colored  fluid  will  at  once  appear  at  the 
external  orifice.  Cystoscopic  examination  will  also  aid  us; 
for  in  ureteral  fistulse  there  is  no  urinary  efflux^  from  the 
corresponding  ureter. 

The  location  of  the  external  opening  of  the  fistula  is  easily 
determined  except  in  those  cases  in  which  its  site  is  in  the 
cervix  uteri,  rectum,  or  vagina.  In  such  cases  considerable 
aid  is  afforded  by  giving  the  patient  a  dose  of  methylene  blue 
and  then  watching  the  suspected  region  for  the  discharge  of 
the  blue-stained  urine. 

The  internal  orifice  of  urethral  fistulse  may  often  be 
located  by  passing  a  metal  instrument  into  the  urethra  and 

1  Fistulae  are  designated  according  to  the  site  of  the  internal  and  external  orifices; 
thus,  vesicovaginal,  ureterovaginal,  etc. 

2  The  efflux  can  be  more  easily  seen  and  watched  if  we  inject  subcutaneously 
twenty  minutes  before  our  cystoscopic  examination  about  thirty  minims  of  a  4  per 
cent,  solution  of  indigo  carmine. 


410     DISEASES  OF   THE  GENITOURINARY  ORGANS 

a  metal  probe  through  the  fistulous  canal  from  the  external 
opening.  Their  frst  point  of  contact  indicates  the  site  of 
the  internal  orifice.  With  tortuous  fistulae  it  may  be  very 
difiicult  to  pass  a  probe;  in  such  cases  the  internal  orifice 
may  be  located  by  endoscopic  examination,  combined  with 
injections  of  colored  fluid  into  the  fistulous  canal. 

Disturbances  of  micturition  are  always  symptomatic  of 
disease  of  the  urogenital  organs,  and  we  should  in  every 
instance  attempt  to  discover  their  underlying  cause.  Nor- 
mally the  urine  should  be  passed  at  regular  intervals  of  several 
hours,  in  a  good-sized  stream,  with  good  force  and  without 
pain.  Extreme  deviations  from  such  a  normal  course  are 
a  total  inability  to  pass  urine  (retention)  and  a  total  inability 
to  retain  any  urine  in  the  bladder  (incontinence).  Lesser 
degrees  of  these  conditions  also  occur. 

Complete  retention  is  due  to  vesical  paralysis,  as  occurs 
in  diseases  or  injuries  of  the  spinal  cord;  to  obstruction  of 
the  ureteral  canal — e.  g.,  by  neoplasm,  foreign  bodies,  calculi, 
etc. ;  to  stricture  of  the  urethra,  to  spasm  of  the  sphincter 
vesicae,  or  to  rupture  of  the  urethra.  With  this  condition 
the  bladder  becomes  distended  and  forms  a  globular  fluctuat- 
ing, tumor  that  gives  a  dull  percussion  note  in  the  hypo- 
gastric region.  The  inability  to  pass  urine  on  account  of  any 
of  the  above  causes  should  not  be  confounded  with  sup- 
pression of  urine,  in  which  condition  no  urine  is  secreted  and 
the  bladder  is  consequently  empty  and  collapsed. 

Obstruction  of  the  urethral  canal  rarely  causes  complete 
retention;  a  little  urine,  if  only  a  few  drops,  can  usually  be 
passed.  The  nature  of  the  obstruction  is  to  be  determined 
from  the  anamnesis,  by  palpation  of  the  prostate,  by  sound- 
ing, and  by  endoscopic  and  cystoscopic  examination. 

Spasm  of  the  vesical  sphincter  may  be  hysterical  or  reflex 
in  character.  Other  neurotic  symptoms  and  variations  in 
the  intensity  of  the  spasm,  together  with  an  absence  of  an 
organic  basis  for  the  spasm,  are  in  favor  of  its  being  hysterical 
in  character,  while  the  presence  of  vesical  inflammation, 
ulceration,  or  other  disease  as  seen  with  the  cystoscope 
signifies  to  its  reflex  nature. 

Incontinence  of  urine — i.  e.,  an  inability  to  hold  urine — 
may  be  complete  or  partial  and  either  functional  or  organic 


DISTURBANCES  OF  MICTURITION  411 

in  nature.  Of  the  functional  incontinence  the  most  famihar 
example  is  the  nocturnal  enuresis  which  is  frequently  met 
with  in  male  children  during  their  early  life  and  which  dis- 
appears spontaneously  when  they  reach  puberty. 

Paralysis  of  and  changes  in  the  sphincter,  foreign  bodies 
which  are  lodged  in  the  internal  urethral  orifice  and  thereby 
interfere  with  sphincteric  closure,  and  large  vesical  fistulae 
lead  to  complete  incontinence. 

Tardiness  in  starting  the  stream  may  be  due  to  general 
muscular  debility,  or  to  disorders  at  the  vesical  neck — i.  e., 
hypertrophied  prostate,  deep  urethral  strictures,  etc. 

Diminution  in  the  calibre  of  the  stream  and  forking  and 
twistings  thereof  as  it  emerges  from  the  urinary  meatus 
point  principally  to  strictures  of  the  urethra,  but  may  also 
be  due  to  obturation  or  compression  of  the  urethra  by  foreign 
bodies,  neoplasms,  etc. 


CHAPTER   XLIIL 

DISEASES  OF  THE  PROSTATE  GLAND,  POSTERIOR 
URETHRA  AND  SEMINAL  VESICLES. 

The  intimate  anatomical  and  physiological  relations  of 
the  prostate  gland,  vesical  neck,  posterior  urethra  and 
seminal  vesicles  explain  their  frequent  simultaneous  involve- 
ment in  disease,  and  the  similar  symptom-complex  that 
attends  their  disorders. 

We  may  broadly  divide  the  maladies  which  affect  these 
organs  into  those  of  an  inflammatory  nature,  whose  chief 
local  manifestations  are  increased  frequency  of  urination, 
painful  urination,  pyuria,  and  hsematuria,  and  those  which 
occasion  a  narrowing,  compression,  or  obturation  of  the 
urethral  canal,  and  manifest  their  presence  by  a  difficulty 
in  passing  water. 

r  INFLAMMATORY  AFFECTIONS. 

P  The  symptoms  attending  this  group  are  similar  to  those 
which  are  provoked  by  allied  affections  of  the  urinary 
bladder,  but  they  have  points  of  difference  that  enable  us 
to  tell  in  which  region  the  disease  is  located.  Thus  in  these 
inflammations  the  pain,  while  present  throughout  the  whole 
act  of  urination,  is  most  severe  at  its  end;  and  when  the 
patient  urinates  into  three  glasses  the  first  one  contains  much 
more  pus  than  do  the  second  and  third.  Should  there  be 
bleeding,  there  will  be  blood  only  in  the  first  glass  if  the 
hemorrhage  is  small;  with  larger  amounts  all  three  glasses 
will  be  bloody,  but  especially  the  first  and  third.  If  these 
data  are  compared  with  those  which  are  obtained  by  exami- 
nation in  cases  of  vesical  disease,  no  difficulty  will  be  experi- 
enced in  determining  the  site  of  the  inflammatory  process. 


DISEASES  OF    THE  PROSTATE   GLAND,  ETC        413 

The  nature  of  the  diseased  process  and  its  further  local- 
ization to  one  or  more  organs  of  this  portion  of  the  genito- 
urinary tract  can  be  determined  from  the  special  character 
of  the  symptoms,  and  by  physical,  endoscopic  and  cystoscopic 
examination.  While  the  last  two  methods  afford  us  the  most 
reliable  and  positive  data  for  diagnosis,  they  cannot  be 
employed  in  the  acute  stages  of  the  inflammatory  diseases 
because  of  the  likelihood  of  increasing  the  severity  of  the 
inflammatory  process  and  because  of  the  exquisite  pain 
w^hich  every  manipulation  with  the  inflamed  parts  during 
this  stage  provokes. 

Urethritis,  Prostatitis,  Vesiculitis. — A  moderate  increase 
in  the  frequency  of  urination  with  slight  pain  and  mild  con- 
stitutional symptoms,  with  no  tenderness  or  enlargement  of 
the  prostate  or  seminal  vesicles,  speaks  for  acute  posterior 
urethritis.  If  the  prostate  is  hot,  enlarged  and  tender,  and 
the  frequency  of  and  pain  on  urination  are  very  marked, 
there  is  an  acute  prostatitis;  abscess  formation  in  this  gland 
is  indicated  by  the  development  therein  of  a  soft  or  fluctuating 
area,  by  an  increase  in  the  severity  of  the  other  symptoms, 
and  by  fever.  It  there  is  doubt  as  to  the  presence  of  pus  an 
exploratory  aspiration  should  be  made  through  the  perineum, 
the  needle  being  guided  into  the  suspected  area  by  the  finger 
in  the  rectum.  Acute  tenderness  and  enlargement  of  the 
seminal  vesicles  so  that  they  can  be  palpated  as  sausage- 
shaped  masses  above  the  prostate  point  to  acute  seminal 
vesiculitis. 

The  appearance  of  shreds  in  the  urine,  with  or  without 
increased  frequency  of  urination,  following  upon  an  acute 
urethritis  is  suggestive  of  a  chronic  posterior  urethritis;  the 
diagnosis  is  confirmed  if  on  endoscopic  examination  the 
mucous  membrane  of  this  portion  of  the  urethral  canal 
appears  dull,  rigid,  irregularly  spotted,  with  its  folds  absent 
or  flattened  out. 

A  urethral  discharge  of  clear,  milky,  or  cloudy,  slimy, 
viscid  fluid  which  varies  in  amount  from  a  few  drops  to  a 
couple  of  teaspoonfuls,  and  which  is  especially  noticed  after 
defecation  and  when  the  stools  are  hard,  together  with  a 
feeling  of  soreness  of  the  posterior  urethra,  and  various 
neurotic  symptoms,  such  as  lassitude,  depression,  etc.,  are 


414     DISEASES  OF  THE  GENITOURINARY  ORGANS 

indicative  of  a  chronic  prostatitis.  In  these  cases  the  prostate 
feels  enlarged  with  areas  of  softening  and  is  prominent  in 
some  places  and  depressed  in  others;  between  the  softened 
areas  the  gland  feels  firmer  than  is  normal.  The  soft  areas 
disappear  after  the  gland  is  massaged  through  the  rectum. 
Upon  cystoscopic  examination  the  prostatic  outline  around 
the  internal  urethral  orifice  is  not  smooth  and  rounded,  but 
irregularly  elevated  and  depressed. 

Prostatic  Tuberculosis. — Firm  nodules  in  the  prostate, 
together  with  hsemospermia,  are  very  suggestive  of  prostatic 
tuberculosis.  Tubercle  bacilli  will  not  be  found  in  the  urine 
or  in  the  prostatic  secretion  until  caseation  of  the  nodules 
occurs;  this  is  indicated  by  softening  of  the  centre  of  the 
nodules.  The  tubercle  bacilli  can  be  best  obtained  by 
expressing  the  prostatic  secretion  through  rectal  massage. 
The  procedure  is  to  be  carried  out  as  follows:  The  urethra 
and  bladder  are  first  thoroughly  cleansed  by  irrigation  and 
the  bladder  filled  with  four  to  six  ounces  of  saline  solu- 
tion. The  gland  is  then  expressed  and  after  this  the  patient 
empties  the  contents  of  the  bladder.  This  fluid  is  centri- 
fuged  or  sedimented  and  the  sediment  is  examined  for 
tubercle  bacilli.^ 

The  presence  of  enlarged,  thickened,  nodular  masses 
corresponding  to  the  site  of  the  seminal  vesicles,  in  con- 
nection with  evidences  of  tuberculosis  in  the  testicles  and 
prostate,  points  to  the  participation  of  these  structures  in 
the  tuberculous  process.^ 

'  Recent  investigations  (Baumgarten)  and  clinical  experience  would  go  to  show 
that  genital  tuberculosis  is  primary  in  the  testicles  and  secondarily  extends  to  the 
seminal  vesicles  and  prostate,  just  as  urinary  tuberculosis  is  primary  in  the  kidneys 
and  secondarily  extends  to  the  ureter  and  bladder.  Extension  to  the  testicle  from 
primary  prostatic  tuberculosis  is  considered  to  be  impossible,  though  it  cannot  be 
denied  that  a  primary  nidus  may  sometimes  be  located  in  the  prostate  and  subse- 
quently extend  to  the  bladder.  If  prostatic  tuberculosis  is,  as  a  general  rule,  second- 
ary to  testicular  tuberculosis,  the  evidences  aiforded  by  the  latter  (see  p.  434)  should 
aid  us  in  the  diagnosis  of  the  former. 

-  The  frequency  with  which  tuberculous  disease  of  the  testicle  is  complicated  with 
tuberculous  aflfection  of  the  prostate  and  seminal  vesicles  should  always  prompt  us  to 
examine  these  latter  organs  before  proceeding  to  radical  operation  upon  the  testicle, 
for  it  is  but  rational  that  if  these  structures  are  involved  a  radical  cure  is  only  possi- 
ble if  they  are  simultaneously  removed,  a  procedure  that  many  surgeons  do  not  look 
upon  with  favor,  especially  if  the  disease  is  bilateral. 


PLATE  VII. 


A.  Hypertrophied  prostate ;  lateral  lobes  projecting  into  the  bladder. 

B.  Hypertrophied  prostate  projecting  into  the  bladder,  with  moderate  trabeculation  of  the 
bladder  walls. 

C.  Marked  trabeculation  of  the  bladder  walls. 

D.  Hypertrophied  prostate  and  vesical  calculi. 

Note  in  all  the  prostatic  pictures  the  greater  or  less  alteration  of  the  normal  prostatic  line 
seen  in  Plate  III.     (From  Nitze.) 


DISEASES  OF   THE  PROSTATE  GLAND,  ETC        415 

OBSTRUCTIVE  DISEASES. 

The  diseases  causing  obstruction  of  the  urethral  canal 
are  enlargements  and  neoplasms  of  the  prostate,  strictures 
of  the  urethra,  calculi  and  foreign  bodies  in  the  urethra,  and 
neoplasms  of  the  urethra.  All  these  affections  give  as  their 
first  and  chief  clinical  manifestation  a  difficulty  in  passing 
water,  and  differentiation  between  them  is  possible  only  by 
a  careful  investigation  of  the  mode  of  onset  and  course  of 
development  of  the  urinary  disturbance,  and  by  a  complete 
local  examination. 

Prostatic  Hypertrophy  and  Atrophy. — The  symptoms 
resulting  from  prostatic  hypertrophy  or  atrophy,  for  by 
raising  a  bar  across  the  neck  of  the  bladder  an  atrophic 
prostate  may  offer  the  same  obstruction  to  urination  as  is 
caused  by  a  hypertrophic  prostate  that  compresses  the 
urethra  or  blocks  its  internal  vesical  orifice  like  a  ball  valve, 
may  be  grouped  into  three  stages :  the  initial  stage  in  which 
there  is  no  urine  retained  in  the  bladder,  the  intermediate 
stage  with  partial  retention,  and  the  final  stage  with  complete 
retention. 

During  the  first  stages  the  individual  is  not  much  disturbed; 
he  must  urinate  somewhat  more  frequently  during  the  night 
as  well  as  during  the  day,  experiences  a  burning  pain  in  the 
urethra,  especially  at  the  glans  penis,  finds  that  he  must  wait  a 
little  longer  than  heretofore  for  the  urine  to  commence  to 
flow,  and  that  the  stream  has  lost  its  force,  the  urine  dropping 
down  between  his  legs.  The  urine  is  clear,  and  the  general 
health  remains  good.  These  symptoms  are  not  constantly  in 
evidence,  nor  always  equally  severe.  They  vary  from  week 
to  week,  and  are  invariably  made  worse  by  any  cause  which 
produces  pelvic  congestion — e.  g.,  constipation,  sexual  over- 
indulgence, and  exposure  to  cold.  The  symptoms  may  not 
increase  materially  for  a  number  of  years,  but  gradually  the 
bladder  becomes  unable  to  entirely  overcome  the  obstruction 
offered  by  the  prostate  and  fails  to  emply  itself  at  each 
urination.  The  retention  of  urine  in  the  bladder  increases 
the  frequency  of  urination  and  occasions  a  chronic  urosepsis, 
which  gives  rise  to  dyspeptic  symptoms.    The  retention  of 


416     DISEASES  OF   THE  GENITOURINARY  ORGANS 

urine  leads  further  to  dilatation  of  the  bladder,  and  this, 
together  with  the  hypertrophy  and  subsequent  degeneration 
of  its  muscular  coat,  which  are  occasioned  by  the  increas- 
ing urethral  obstruction,  ultimately  result  in  complete  reten- 
tion of  urine. 

Acute  complete  retention  may  set  in  at  any  time  during 
the  first  two  stages  from  acute  congestion  of  the  gland;  in 
fact,  such  acute  retention  is  often  the  very  first  sign  of  the 
hypertrophied  prostate.  Repeated  attacks  of  acute  complete 
retention  may  occur  or  the  acute  complete  retention  may  be 
followed  by  a  chronic  partial  retention.  At  any  time  the 
symptoms  are  made  considerably  worse  by  an  infection  of 
the  bladder  and  kidneys. 

The  diagnosis  of  prostatic  enlargement  or  atrophy  is  made 
by  palpating  the  gland  through  the  rectum,  and  by  the 
cystoscope,  while  the  presence  of  residual  urine  is  determined 
by  the  urethral  catheter. 

As  a  rule,  an  enlargement  of  the  prostate  can  be  appre- 
ciated through  the  rectum.  Its  consistency  varies;  some- 
times it  is  soft,  again  firm,  and  it  may  contain  isolated,  firm, 
elastic  nodules.  The  rectal  wall  is  movable  upon  the  gland. 
It  is  desirable  during  the  palpation  to  try  and  feel  the  upper 
border  of  the  gland,  so  as  to  ascertain  the  upper  limits  of  the 
enlarged  organ.  It  must  not  be  assumed,  however,  that  every 
prostate  that  causes  prostatic  symptoms  feels  enlarged  through 
the  rectum.  Very  often  the  limits  and  surface  configuration  as 
far  as  can  be  made  out  per  rectum  are  not  materially  changed, 
and  in  not  a  few  cases  the  gland  feels  smaller  and  firmer 
than  is  normal.  In  the  presence  of  prostatic  symptoms, 
when  the  palpating  finger  is  unable  to  detect  sufficient 
enlargement  of  the  organ  to  account  for  them,  a  further 
examination  is  necessary  in  order  to  arrive  at  a  diagnosis; 
for  stricture  of  the  urethra  and  muscular  weakness  of  the 
bladder  from  general  arteriosclerosis  give  a  clinical  picture 
that  much  resembles  prostatism. 

In  just  these  cases  does  cystoscopy  find  its  chief  diagnostic 
value.  As  a  rule  instrumentation  is  to  be  avoided  in  pros- 
tatics,  for  these  patients  are  very  easily  infected;  but  when 
it  is  necessary  for  diagnosis  no  hesitancy  should  be  had  in 
resorting  to  it,  provided  the  very  strictest  aseptic  and  anti- 


DISEASES  OF   THE  PROSTATE  GLAND,  ETC         417 

septic  precautions  are  observed.  The  cystoscope  shows  the 
enlarged  prostate  bulging  into  the  bladder,  and  with  a  retro- 
grade cystoscopic  instrument  its  encroachments  upon  the 
urethral  orifice  can  be  distinctly  seen.  The  hypertrophied 
middle  lobe  and  prostatic  bar,  when  present,  are  readily 
made  out,  and  the  trabeculated  bladder,  with  its  pouches 
and  diverticula  and  possibly  calculi,  are  clearly  seen. 

Should  partial  retention  of  urine  be  suspected,  its  presence 
can  be  demonstrated  by  the  urethral  catheter.  Catheter- 
ization belongs  in  the  same  category  as  other  instrumentation, 
and  in  its  employment  the  strictest  aseptic  precautions  are 
to  be  observed.  The  patient  first  passes  all  the  urine  he  can, 
then  the  catheter  is  inserted,  and  the  presence  and  amount  of 
residual  urine  determined. 

The  symptoms  above  described  as  resulting  from  prostatic 
hypertrophy  and  atrophy  are  closely  simulated  by  those 
which  are  occasioned  by  stricture  of  the  urethra,  vesical 
tumors,  prostatic  neoplasms,  and  degeneration  of  the  vesical 
wall  from  arteriosclerosis. 

Stricture  of  Urethra. — Stricture  of  the  urethra  occurs,  as 
a  rule,  in  younger  subjects,  and  is  preceded  by  one  or  more 
attacfo  of  gonorrhoea,  to  which  the  urinary  disturbance  can 
be  distinctly  traced.  The  stream  with  stricture  is  forked 
and  twisted.  Examination  of  the  urethra  by  sounds  demon- 
strates its  stenosis,  while  with  the  endoscope  the  diaphragm 
or  funnel-shaped  contraction  of  the  canal  is  seen.  The 
prostate  does  not  feel  enlarged  per  rectum,  and  if  a  cystoscope 
can  be  passed  into  the  bladder,  no  median  lobe,  no  prostatic 
bar,  nor  bulging  lateral  lobes  are  to  be  seen.  The  association 
of  prostatic  hypertrophy  with  stricture  is  diagnosed  from  the 
presence  of  clinical  symptoms  and  objective  findings  belong- 
ing to  both  diseases. 

Vesical  Tumors. — Vesical  tumors  do  not  give  the  same 
clinical  history.  With  them  hemorrhage  is  often  the  first 
symptom,  and  difficulty  in  passing  urine  is  experienced  only 
when  the  growth  encroaches  on  the  urethral  orifice.  Early 
cachexia,  inguinal  glandular  enlargement,  the  presence  of  a 
hard,  infiltrating  tumor  which  can  be  appreciated  per  rectum, 
and,  chief  of  all,  the  cystoscopic  picture  will  permit  a  differ- 
entiation from  prostatic  hypertrophy  to  be  made. 

27 


418     DISEASES  OF   THE  GENITOURINARY  ORGANS 

Malignant  Tumors  of  Prostate. — Malignant  tumors  of 
the  prostate  are  in  their  early  stages  very  difficult,  if  not 
impossible,  to  differentiate  from  benign  prostatic  hypertro- 
phy. The  former  occur  in  the  young  as  well  as  the  old, 
but  they  are  harder,  more  irregular,  more  rapidly  growing 
tumors,  and  are  attended  with  cachexia  and  enlargement  of 
the  inguinal  glands.  They  more  frequently  give  rise  to  hsem- 
aturia. 

Retention  of  Urine. — Retention  of  urine  without  prostatic 
disease,  as  occurs  with  arteriosclerosis  and  muscular  degen- 
eration of  the  vesical  wall,  is  to  be  recognized  by  the  absence 
of  a  prostatic  enlargement,  by  the  absence  of  an  elongated 
posterior  urethra,  and  by  the  presence  of  general  arterio- 
sclerosis. 

Urethral  Calculi. — The  difficulty  in  urination  that  is  due 
to  the  impaction  of  a  calculus  in  the  urethra  is  usually 
attended  with  urethral  tenesmus,  pain,  and  sometimes  with 
hsematuria  and  pyuria.  The  previous  history  will,  as  a  rule, 
suggest  the  presence  of  a  stone  in  the  kidney  or  bladder. 
The  diagnosis  is  readily  confirmed  in  suspected  cases  by 
passing  a  metal  searcher  into  the  urethra;  if  a  calculus  is 
present  a  grating  sensation  will  be  experienced.  Sometimes 
a  calculus  that  forms  in  the  prostate  protrudes  into  the 
urethra  and  occasions  more  or  less  difficulty  in  urination, 
pain,  pyuria,  and  hsematuria.  Its  presence  is  recognized 
from  the  hard,  nodular,  circumscribed  mass  in  the  prostate, 
and  by  x-raj  examination. 

Neoplasms  of  Urethra. — Neoplasms  of  the  urethra 
only  interfere  with  the  lumen  of  the  canal  when  they 
attain  some  size.  Papillomata  occur  in  any  part  of  the 
canal,  but  most  frequently  near  the  external  meatus.  They 
occasion  a  seroturbid  urethral  discharge  that  is  often 
attributed  to  a  gonorrhoeal  infection.  A  small  papillary 
growth  on  the  external  meatus  with  a  seroturbid  urethral 
discharge  should  suggest  the  possibility  of  more  such  growths 
being  present  deeper  down  in  the  canal,  and  should  prompt 
us  to  make  an  endoscopic  examination.  A  malignant  tumor 
should  be  thought  of  if  with  the  evidences  of  urethral  obstruc- 
tion, such  as  go  with  stricture  of  the  urethra,  there  is  a  hard, 
irregular,  infiltrating  tumor  of   the  urethra,  to  account  for 


DISEASES  OF   THE  PROSTATE  GLAND,  ETC        419 

which  there  is  present  neither  a  gonorrhoeal  periurethritis 
nor  a  stricture  of  the  urethra.  As  the  mahgnant  tumors 
are  rarely  primary  growths,  the  original  focus,  which  is  most 
frequently  located  in  the  rectum  or  prostate,  should  be 
sought  for. 

A  smooth,  elastic  tumor  in  the  neighborhood  of  Cowper's 
glands  with  or  without  urinary  disturbance  is  suggestive  of 
a  retention  cyst  of  this  organ. 


CHAPTER   XLIV. 

INJURIES  OF  THE   URETHRA  AND  URINARY  EXTRAVA- 
SATION:   URETHRAL  FEVER. 

Infiltration  with  urine  of  the  cellular  tissues  of  the 
thigh,  buttocks,  hypogastrium,  scrotum,  and  penis  has  its 
most  frequent  cause  in  injuries  of  the  urethra,  whether  sus- 
tained by  accidental  trauma  or  by  instrumentation;  it  like- 
wise follows  rupture  of  the  urethra  from  destructive  inflam- 
mations thereof  and  spontaneous  rupture  of  a  weakened 
portion  of  the  canal — e.  g.,  behind  a  stricture.  Not  every 
injury  of  the  urethra  is  attended  with  urinary  extravasation. 
The  lesser  injuries — e.  g.,  a  false  passage,  etc. — are  apt  to 
be  followed  only  by  hemorrhage  into  the  canal,  or  by  a  sub- 
mucous hsematoma;  the  blood  in  the  urethra  appears  at  the 
external  meatus  if  the  site  of  the  injury  is  in  front  of  the 
triangular  ligament,  otherwise  it  flows  back  into  the  bladder 
and  is  voided  with  the  urine.  A  large  hsematoma  may 
occlude  the  urethra  and  cause  difficulty  in  urination,  even 
complete  retention;  it  appears  immediately  after  the  recep- 
tion of  the  injury  and  forms  a  soft,  doughy,  somewhat 
tender  tumor. 

Tearing,  laceration,  or  perforation  of  the  urethra  leads, 
as  a  rule,  to  urinary  extravasation.  If  the  solution  of  con- 
tinuity is  in  front  of  the  triangular  ligament,  the  urine 
extravasates  into  the  scrotum  and  penis,  down  the  thighs 
and  upon  the  abdominal  wall;  if  it  is  behind  the  triangular 
ligament,  the  urine  infiltrates  into  the  cellular  tissue  of  the 
pelvis  and  space  of  Retzius.  When  the  extra vasated  urine 
occupies  the  superficial  structures,  these  rapidly  become 
swollen,  red,  and  gangrenous  in  patches,  and  severe  consti- 
tutional symptoms,  high  temperatures,  rapid  pulse  rate,  and 
prostration  develop.  When  it  is  located  in  the  deeper 
cellular   tissues    a   rapidly   spreading,    brawny,    exquisitely 


INJURIES  OF   URETHRA:    URETHRAL  FEVER     421 

painful,   somewhat   fluctuating  swelling  appears,    attended 
with  very  severe  constitutional  disturbances. 

Very  small  tears  may  be  followed  by  the  formation  of  a 
small  abscess  at  the  site  of  the  injury,  which  may  in  turn 
perforate  into  the  urethra  or  externally,  with  or  without  the 
formation  of  a  urinary  fistula. 

The  existence  of  an  injury  or  rupture  of  the  urethra  is 
readily  ascertained  from  a  history  of  accidental  trauma  or 
instrumentation,  from  the  presence  of  a  destructive  inflam- 
mation of  the  urethral  wall,  or  from  an  old  history  of 
stricture  followed  by  the  sudden  appearance  of  extravasated 
urine.  The  appearance  of  blood  at  the  meatus  or  of  a 
large  hsematoma  in  the  perineum  after  an  injury  or  after 
instrumentation  points  to  a  lesion  of  the  urethra.  If  a 
catheter  can  be  easily  passed  into  the  bladder  and  clear 
urine  is  withdrawn  therefrom,  and  if  the  patient  is  able 
to  void  urine  spontaneously,  the  solution  of  continuity 
cannot  be  very  large.  If,  on  the  other  hand,  a  catheter 
cannot  be  passed  into  the  bladder,  and  the  patient  cannot 
urinate,  the  defect  must  be  extensive.  The  examiner  must 
be  cautious  in  interpreting  the  findings  with  the  catheter. 
Thus  the  patient  may  urinate  spontaneously  into  a  pouch  in 
the  cellular  tissue  at  the  site  of  the  injury,  and  the  catheter 
passing  into  this  space  withdraws  clear  urine  or  bloody 
urine,  giving  the  impression  that  no  severe  injury  of  the 
urethra  has  taken  place.  By  measuring  the  length  of  the 
part  of  the  catheter  that  must  be  passed. until  urine  com- 
mences to  flow,  it  will  be  found  that  this  does  not  correspond 
with  the  length  of  the  urethral  canal,  and  further,  with  the 
finger  in  the  rectum  or  on  the  perineum,  it  will  be  found  that 
the  catheter  has  not  been  passed  through  the  entire  canal. 
The  rapid  development  of  urinary  extravasation  at  once 
points  to  a  severe  urethral  injury. 


URETHRAL  FEVER. 

We  have  already  alluded  to  the  fact  that  the  passage  of 
an  instrument  into  the  urethra  is  a  serious  and  important 
surgical  procedure,  on  account  of  the  risks  it  entails  of  carry- 


422     DISEASES  OF  THE  GENITOURINARY  ORGANS 

ing  infection  to  the  upper  urinary  organs.  In  some  indi- 
viduals, especially  those  who  are  susceptible  to  infections 
and  those  whose  urine  is  foul  and  septic,  instrumentation  of 
any  kind,  even  though  done  with  the  greatest  of  aseptic  and 
antiseptic  precaution,  is  apt  to  be  followed  by  a  chill  and 
high  rise  of  temperature.  Some  of  the  patients  become 
seriously  ill,  the  high  fever  continues,  and  death  may  follow 
in  twenty-four  hours  of  profound  sepsis.  In  others  the  fever 
subsides  in  a  few  days,  with  complete  recovery  of  the  patient. 
Local  evidences  of  infection  may  be  altogether  wanting,  or 
the  kidneys  become  enlarged  and  tender  or  a  severe  cystitis 
develops. 


CHAPTER    XLV. 

DISEASES  OF  THE  EXTERNAL  GENITAL  ORGANS, 
TESTICLE,  AND  CORD. 

ABNORMALITIES. 

Abnormalities  in  the  position  of  the  meatus  urinarius — ■ 
e.  g.,  epispadias  (on  the  dorsum  of  the  penis),  hypospadias 
(on  the  ventral  surface) — and  abnormahties  in  the  tightness 
of  the  foreskin,  phimosis  (excessive  tightness),  need  only  to 
be  seen  to  be  recognized.  Paraphimosis  results  when  a  very 
tight  foreskin  is  drawn  back  over  the  glans  and  cannot  be 
reduced  again.  If  the  glans  is  constricted  by  the  tight 
foreskin,  strangulation  and  ultimate  necrosis  thereof  will 
take  place. 

ULCERATIONS. 

Ulcerations  of  the  external  genitals  may  be  venereal  (soft 
or  hard  chancres),  cancerous  (epitheliomatous),  and  rarely 
tuberculous.  In  contrast  to  the  hard  chancre  the  soft  sore 
has  a  shorter  period  of  incubation,  is  usually  multiple, 
secretes  more  profusely,  has  not  the  indurated  edges,  and  is 
usually  attended  with  unilateral,  instead  of  bilateral,  inguinal 
glandular  swelling.  Furthermore,  the  glandular  involve- 
ment is  of  the  dolent  type  instead  of  the  indolent,  as  goes 
with  the  hard  chancre.  The  soft  chancre  may  be  atonic 
(no  tendency  to  heal),  or  attended  with  considerable  inflam- 
matory reaction,  or  phagedenic,  or  serpiginous,  or  gangrenous. 

Tuberculous  Ulcerations. — Tuberculous  ulcerations  are 
infrequent,  and  more  common  in  the  female  than  in  the  male. 
They  are  always  secondary  to  tuberculosis  of  other  parts  of 
the  genital  tract,  and  have  an  irregular,  worm-eaten,  cheesy 
base. 


424     DISEASES  OF   THE  GENITOURINARY  ORGANS 

Cancerous  Ulcerations.^ — Cancerous  gro^'ths  of  this 
region  are  most  frequently  of  the  epithehomatous  type, 
rarely  of  the  medullary  variety.  The  former  commence  as 
indurated,  papillary  excrescences  that  rapidly  break  down, 
leaving  an  everted,  indurated  ulcer  with  a  crusty,  easily 
bleeding,    unhealthy,    granulating   base.     The    latter  com- 


FiG. 149 


^\^- 


Chimney-sweep's  carcinomata  of  the  penis  and  scrotum.    (Bramann.) 


mence  as  circumscribed,  indurated  nodules  that  lapidly  fuse 
together  and  break  down,  leaving  an  everted,  indui:;ted  ulcer 
with  exuberant  bleeding,  granulating  base.  The  surface  of 
the  foreskin  and  the  surface  of  the  vulva  which  opp  j  -e  the 
seat  of  the  neoplasm  are  very  liable  to  contact  infection. 

Acuminate  Condylomata. — Acuminate  condylomata  form 
fine  papillary  excrescences  without  induration. 


GENITAL  ORGANS,   TESTICLE,   CORD  425 

Herpes  Progenitalis. — Herpes  progenitalis  manifests  itself 
by  a  group  of  small  vesicles  which  rapidly  burst,  leaving 
superficial,  not  indurated  erosions,  which  heal  readily  under 
a  soothing  ointment.  Their  tendency  to  recurrence  adds 
another  characteristic  to  them. 

Benign  Nodular  Infiltrations. — Benign  nodular  infiltra- 
tions of  the  penis  are  not  uncommonly  encountered  and  are 
sometimes  mistaken  for  cancer.  Such  nodules  are  either 
gummata,  or  gouty  nodes,  or  distended,  chronically  inflamed 
follicles  with  considerable  fibrous  induration  around  them, 
or  they  are  thickened  lymphatics  arising  from  an  eczema 
of  the  penis.  Gummata  occur  only  in  syphilitics  and  are 
elastic  and  firm.  Distended  follicles  are  preceded  by  a  history 
of  gonorrhoea;  they  are  of  slow  growth  and  painless.  Gouty 
nodes  are  attended  with  other  evidences  of  this  disease — 
e.  g.,  deposits  on  the  fingers  and  toes,  in  the  tendon-sheaths, 
and  around  the  larger  joints. 

These  nodes  are  distinguished  from  malignant  deposits  by 
their  softer  consistency,  and  by  their  circumscribed,  non- 
infiltrating character. 

Prolapse  of  the  anterior  and  posterior  vaginal  walls 
(cystocele  and  rectocele),  retention  cysts  of  the  vaginal  walls, 
retention  cysts  of  Bartholini's  gland,  and  suppurations  of  the 
latter  are  readily  recognized  when  seen. 


SCROTAL  SWELLINGS. 

It  is  of  prime  importance  in  the  diagnosis  of  scrotal 
swellings  to  determine  whether  they  originate  in  the  struc- 
tures of  the  cord  or  testicle  or  whether  they  project  into  the 
scrotum  from  the  abdominal  cavity.  The  latter  class  is 
characterized  by  entire  reducibility^  into  the  abdominal 
cavity,  by  an  impulse  on  coughing,  and  by  the  fact  that  they 
extend  into  and  fill  the  inguinal  canal.  If  the  swelling 
reduces  with  a  gurgle  and  is  tympanitic  to  percussion,  it  is 
a  hernia  of  the  intestine;  if  it  is  soft  and  doughy  and  dull 
to  percussion  and  does  not  reduce  with  a  gurgle,  it  is  a 

1  The  swelling  may  have  lost  its  reducibility,  but  the  other  characteristics  remain. 


426     DISEASES  OF   THE  GENITOURINARY  ORGANS 

hernia  of  the  omentum;  if  it  reduces  slowly  without  a  gurgle 
and  is  fluctuating  and  translucent,  it  is  a  hydrocele  of  the 
open  processus  vaginalis  peritonei;  if  it  is  only  partially 
reducible,  but  has  the  other  characteristics  just  enumerated, 
and  if  upon  reduction  a  fluctuating  swelling  appears  beneath 
the  aponeurosis  in  the  inguinal  region  which  later  becomes 

Ftg. 150 


Bilocular  hydrocele,  partially  intra-abdominal.    Before  operation.    (Von  Bergmann.) 

tense  when  the  scrotal  portion  of  the  swelling  is  compressed, 
it  is  a  bilocular  hydrocele. 

Swellings  in  the  scrotum  that  have  not  the  characteristics 
of  reducibility  and  impulse  on  coughing  originate  in  the  cord 
or  testicle. 

If  the  swelling  is  funicular  in  origin,  a  fact  that  is  easily 
recognized  by  the  ability  to  palpate  a  normal  testicle  below 


GENITAL  ORGANS,   TESTICLE,   CORD 


427 


it,  it  is  either  a  hydrocele  or  hsematocele,  or  varicocele,  or 
lipoma. 

Hydrocele. — A  hydrocele  of  the  cord — i.  e.,  a  collection 
of  serum  in  the  unobliterated  remains  of  the  processus 
vaginalis — forms  a  smooth,  rounded,  or  cylindrical,  usually 
tense,  fluctuating,  and  translucent  tumor.  Translucency 
may  be  absent  if  the  sac  of  the  hydrocele  is  much  thick- 
ened or  calcareous,  a  condition  that  is  often  found  in  the 


Fig. 151 


Acquired  inguinal  hernia  in  front  of  the  hydrocele  of  the  cord.    (Von  Bergmann.) 

long-standing  cases.  Sometimes  the  fluid  is  encapsulated 
in  several  compartments,  thus  constituting  the  multilocular 
hydroceles. 

Hsematocele. — An  hsematocele  forms  a  soft,  doughy,  semi- 
fluctuating,  tense  swelling,  and  usually  develops  after  a 
trauma  to  this  organ,  or  follows  upon  a  puncture  of  a  pre- 
existing hydrocele  sac.  The  hemorrhagic  infiltration  of  the 
subcutaneous  tissues,  the  clinical  history  of  the  case,  and  the 


428     DISEASES  OF   THE  GENITOURINARY  ORGANS 

absence  of  translucency  without  a  marked  thickening  of  the 
sac  readily  distinguish  these  swelhngs  from  hydroceles. 

Lipomata. — Lipomata  of  the  cord  form  diffuse,  soft,  semi- 
fluctuating  tumors,  which  are  distinguished  from  the  pre- 
ceding swellings  by  the  absence  of  true  fluctuation,  trans- 
lucency,  and  tenseness.  In  doubtful  cases  aspiration  will  at 
once  enable  us  to  determine  the  character  of  the  swelling. 

Fig. 152 


Acquired  inguinal  hernia  with  hydrocele  of  the  sac.    (Von  Bergmann.) 


Varicocele.— Dilatation  and  tortuosity  of  the  veins  of  the 
cord  (spermatic  plexus)  constitute  a  varicocele,  which  is 
readily  recognized  by  the  compressibility  and  earth-worm 
feel  of  the  mass,  and  by  its  disappearance  when  the  patient 
is  recumbent.  It  is  most  often  found  on  the  left  side,  and  is 
accompanied  by  dilatation  of  the  superficial  scrotal  veins, 
and  by  atrophy  of  the  corresponding  testis.    It  may  be  con- 


GENITAL  ORGANS,    TESTICLE,  CORD 


429 


founded  with  an  epiplocele  (hernia),  but  the  reducibihty  of 
the  latter  into  the  abdomen  and  its  impulse  on  coughing 
readily  distinguish  it. 

Hydrocele  of  Tunica  Vaginalis  Testis. — Hydrocele  and 
hsematocele  of  the  tunica  vaginalis  testis  have  the  same 
characteristics  as  similar  conditions  of  the  cord,  from  which 
they  are  to  be  distinguished  by  the  fact  that  they  encircle 
and  hide  the  testicle.     Hernise  and  hydroceles  of  the  testis 

Fig. 153 


Hydrocele  of  the  tunica  vaginalis.    (Von  Bergmann.) 


may  exist  together;  if  the  hernia  lies  above  the  hydrocele, 
there  is  a  reducible,  non-translucent  tumor  above,  and  an 
irreducible,  translucent,  fluctuating  tumor  below;  if  the 
hernia  invaginates  itself  into  the  hydrocele  (encysted  hernia), 
there  is  a  tense,  fluctuating,  non-reducible  swelling  which 
surrounds  a  reducible,  non-fluctuating  one. 

Spermatocele. — Spermatoceles  (cysts  of  the  testicle)  possess 
some  of  the  characteristics  of  hydroceles  of  the  tunica  testis, 
but  they  are  distinguished  from  them  by  the  fact  that  as  they 
usually  lie  between  the  testicle  and  epididymis,  they  do  not 
cover  the  front  and  sides  of  the  testicle  as  do  the  hydroceles. 
Hydrocele  of  the  cord  is  differentiated  from  spermatocele  by 


430     DISEASES  OF  THE  GENITOURINARY  ORGANS 

the  fact  that  in  this  condition  the  testicle  can  be  isolated 
from  the  tumor,  which  is  not  possible  in  the  case  of  a  sper- 
matocele. In  doubtful  cases  exploratory  aspiration  and 
examination  of  the  fluid  under  the  microscope  for  sperma- 
tozoa will  clear  up  the  diagnosis. 

Swellings  of  Epididymis. — Swellings  of  the  epididymis  are 
to  be  differentiated  from  those  of  the  testicle  proper  by  their 
crescentic  shape,  in  the  hollow  of  which  lies  the  globular 

Fig. 154 


Encysted  hernia  with  invagination  of  a  hydrocele  of  the  tunica  vaginalis. 
(Von  Bergmann.) 


testicle.  Tumors  of  the  testicle  are  of  globular  shape;  their 
outlines  may  be  obscured  by  a  hydrocele  which  accompanies 
the  diseased  process,  and  we  should,  therefore,  always  be 
guarded  in  expressing  an  opinion  as  to  the  condition  of  the 
testicle  until  the  hydrocele  fluid  has  been  removed. 

Rapid  enlargement,  exquisite  pain,  and  tenderness,  with 
temperature  elevations,  are  evidences  of  acute  inflammatory 
conditions  of  the  testicle  or  epididymis,  the  cause  for  which 


GENITAL   ORGANS,    TESTICLE,   CORD 

Fig. 155 


431 


Hydrocele  of  the  tunica  vaginalis  with  acquired  inguinal  hernia.    (Von  Bergmann.) 

Fig. 156 


Spermatocele  between  the  testis  and  epididymis,  giving  the  testis  a  horizontal 
position.    (Kocher.) 


432     DISEASES  OF  THE  GENITOURINARY  ORGANS 

Fig. 157 


Intra  vaginal  spermatocele.    CVon  Bergmanu. 
Fig.  158 


Showing  the  relations  of  the  testis  and  epididymis  in  acute  orchitis  ;  H,  testis  ;  Nh, 
epididymis;  a,  sagittal  section  ;  6,  horizontal  section.    (Kocher.) 


GENITAL  ORGANS,   TESTICLE,   CORD 


433 


must  be  sought  in  a  posterior  urethritis  or  in  an  acute  infec- 
tious disease,  especially  likely  being  mumps,  typhoid  fever, 
or  some  eruptive  fever.  The  enlargement  of  the  testicle 
which  sometimes  remains  after  an  acute  inflammation  bears 
a  strong  resemblance  to  chronic  orchitis  from  syphilis,  and 
in  the  absence  of  a  syphilitic  history  the  diagnosis  is  always 
uncertain.  If  the  swelling  is  very  hard,  has  a  smooth  and 
regular  outline,  is  limited  to  the  body  of  the  testicle,  is  ac- 

FiG. 159 


Illustrating  the  relations  of  the  epididymis  and  testis  in  acute  epididymitis.  In  the 
first  drawing  the  head  of  the  epididymis  is  chiefly  aft'ected,  and  in  the  second  draw- 
ing, the  tail ;  H,  testis  ;  Nh,  epididymis ;  S,  spermatic  cord.    (Von  Bergmann.) 


companied  by  a  hydrocele,  and  does  not  impart  the  testicular 
sensation  when  it  is  compressed,  it  is  probably  syphilitic. 

A  chronic  orchitis  is  to  be  differentiated  from  a  chronic 
hydrocele  with  much  thickened  and  calcareous  sac  by  the 
fact  that  with  the  latter  condition  the  tumor  is  in  some 
places  of  very  hard,  almost  bony  consistency. 

Syphilitic  Gummata. — Prior  to  softening  and  perforation, 
syphilitic  gummata  of  the  testicle  cannot  be  distinguished 
from  a  diffuse  syphilitic  orchitis.  After  perforation  they  may 
be  confused  with  tuberculosis  or  neoplasm  of  the  testicle, 
but  the  regular  margins  of  the  fistulous  opening,  the  profuse 
serous  discharge  therefrom,  and  the  absence  of  secondary 

28 


434     DISEASES  OF  THE  GENITOURINARY  ORGANS 

foci  in  the  cord,  prostate,  and  seminal  vesicles,  together  with 
a  syphilitic  history  and  other  evidences  of  this  disease,  serve 
to  differentiate  them.  Gummatous  nodules  in  the  epididy- 
mis may  be  confused  with  the  nodules  in  this  organ  that 
result  from  a  preceding  gonorrhoeal  infection,  but  those  due 
to  syphilis  are  usually  located  in  the  globus  major,  while 
those  due  to  gonorrhoea  are,  as  a  rule,  in  the  globus  minor. 

Tuberculous  Disease. — Tuberculous  disease  of  the  testicle 
occurs  most  frequently  in  young  subjects  who  have  other 
foci  of  tuberculous  disease  or  who  have  a  family  predispo- 
sition for  this  affection.  The  epididymis  is  first  attacked 
and  becomes  nodulated.  This  location  in  the  early  stages 
distinguishes  it  from  syphilis  and  neoplasm.  Later  on  it 
spreads  to  and  invades  the  testicle,  vas,  prostate,  and  seminal 
vesicles.  The  nodules  soften,  break  down,  and  become 
adherent  to  the  skin  and  ulcerate  through  it.  The  cheesy, 
worm-eaten  edges  of  the  ulcers,  the  seropurulent  discharge, 
and  the  presence  of  other  nodules  in  the  vas,  prostate,  and 
vesicles  serve  to  distinguish  this  condition  from  the  other 
inflammatory  and  neoplastic  diseases  of  the  testicle.  If  both 
epididymes  and  testicles  are  involved  there  is  no  further 
doubt  about  the  diagnosis. 

Benign  Neoplasms. — Benign  neoplasms  of  the  testicle 
grow  slowly,  and  remain  encapsulated,  whereas  malignant 
growths  increase  in  size  rapidly,  and  extend  at  an  early  period 
to  the  epididymis  and  lumbar  glands.  All  neoplasms  of  the 
testicle  impart  a  feeling  of  great  weight  to  the  organ,  which 
at  once  distinguishes  them  from  the  inflammatory  conditions. 

Sarcomata  are  most  frequent  in  young  individuals;  they 
grow  rapidly  and  are  quite  soft  in  consistency.  The  carci- 
nomata  are  hard,  grow  less  rapidly,  and  are  most  common  in 
advanced  life.  Prior  to  perforation  a  sarcomatous  tumor 
may  resemble  a  gumma  or  syphilitic  orchitis,  but  mixed 
treatment  has  no  marked  influence  upon  it,  the  patient  does 
not  give  a  distinct  syphilitic  history  and  does  not  show  other 
evidences  of  the  specific  disease.  In  all  doubtful  cases 
exploratory  incision  is  to  be  resorted  to  as  early  as  possible. 
After  perforation  the  fungous  character  of  the  ulcer,  the 
rapid  enlargement  of  the  tumor,  and  the  presence  of  secondary 
deposits  readily  enable  one  to  make  the  diagnosis. 


PLATE  VIII. 


Fracture  of  the  Femur,  showing  considerable  Vertical 
and  Lateral  Displacement  of  the  Fragments,  vv^ithout  change 
In  the  External  Contour  of  the  Limb. 


PART  VI. 
INJURIES  AND  DISEASES  OF  THE  EXTREMITIES. 


CHAPTER   XLVL 
INJURIES  OF  THE  BONES. 

The  x-t&j^  has  simplified  the  recognition  of  fractures,  and 
made  the  determination  of  their  direction,  their  number,  and 
the  displacement  of  the  fragments  very  much  more  certain. 
Even  in  the  apparently  simple  cases  this  method  of  exam- 
ination should  be  employed  wherever  possible,  if  only  to 
confirm  the  other  clinical  findings. 

In  addition  to  this  positive  and  accurate  method  for  the 
diagnosis  of  fractures  and  other  injuries  of  the  bones  there 
are  other  clinical  signs  by  which  the  presence  of  a  fracture 
may  be  determined,  though  the  relation  of  the  fragments  to 
each  other  and  the  direction  of  their  displacement  cannot 
be  as  well  elicited  by  them  as  by  the  x-ray  examination. 

These  clinical  evidences  are  swelling  and  ecchymosis  in 
the  region  where  the  injury  was  inflicted,  and  extending 
from  here  up  and  down  the  limb,  change  in  the  axis  of  the 
limb  (either  an  angular  deviation  of  its  own  axis,  or  dis- 
placement of  its  entire  axis  inward  or  outward  in  reference 
to  neighboring  fixed  points),  local  tenderness  over  the  frac- 
ture, crepitus  on  rubbing  the  apposed  surfaces  together, 
shortening  of  the  limb,  false  point  of  motion  in  the  limb, 
and  usually  a  loss  of  active  motility. 

1  The  use  of  the  a;-rays  in  the  treatment  of  fractures,  to  determine  whether  the 
fragments  are  in  good  apposition,  need  only  to  be  mentioned  to  at  once  suggest  its 
great  value  to  those  who  are  not  accustomed  to  systematically  employ  the  rays  for 
this  purpose. 


436     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

Method  of  Examination  for  Fracture. — ^A  patient  who  has 
sustained  an  injury  to  his  Hmbs  should  be  examined  in  the 
following  manner:  He  should  be  undressed,  the  clothing  if 
necessary  being  cut  away,  so  as  to  expose  the  injured  and 

Fig. 160 


Angular  deviation  of  the  axis  of  the  left  thigh  due  to  fracture  of  the  femur. 


the  uninjured  extremity.  His  attitude,  his  position;  the 
manner  in  which  he  carries  the  injured  part;  the  presence 
of  external  wounds,  of  projecting  bones,  of  ecchymoses ;  the 
axis  of  the  limb  (its  own  integrity  and  its  direction  to  neigh- 
boring fixed  points),  and  the  possibility  of  active   motion 


INJURIES  OF   THE  BONES  437 

should  all  be  carefully  noted.  In  other  words,  all  the 
information  that  can  be  obtained  by  inspection  should  be 
elicited  before  the  injured  limb  is  touched.  The  tip  of  a 
single  finger  should  then  be  passed  along  the  entire  length 
of  the  bone,  the  patient  being  asked  to  state  when  he  feels 
an  acute,  sharp  pain  (as  the  location  of  this  corresponds  to 
the  seat  of  fracture,  the  examiner  knows  at  once  where  to 
look  for  crepitus  and  false  point  of  motion).  The  length 
of  the  limb  should  then  be  measured  and  compared  with 
that  of  the  opposite  side,  and  the  relation  of  fixed  points  on 
it  to  fixed  points  on  neighboring  parts  should  also  be  ascer- 
tained. Open  wounds  should  not  be  probed,  but  after  being 
thoroughly  cleansed  they  should  be  covered  by  an  aseptic 
dressing.  In  every  detail  of  the  examination  comparison 
of  the  injured  with  the  healthy  side  should  be  made. 

With  such  a  routine  method  of  examination  it  is  possible 
to  determine  the  probable  presence  of  a  fracture  by  inspec- 
tion alone.  It  is  never  right,  however,  to  rely  upon  this 
means  alone  for  making  the  diagnosis.  The  data  it  affords 
should  always  be  reinforced  by  those  that  are  to  be  obtained 
by  palpation,  measurement,  and  the  a^-ray  examination. 


SPECIAL  FEATURES  OF  FRACTURES  OF  THE  INDI- 
VIDUAL BONES. 

Only  the  fractures  of  the  shafts  of  the  long  bones  will  be 
here  considered;  those  of  the  articular  ends  of  the  bones 
will  be  included  under  injuries  of  the  joints. 

Fractures  of  the  Clavicle. — The  attitude  of  a  patient  who 
has  sustained  a  fracture  of  the  collar  bone  is  characteristic. 
His  head  is  inclined  to  the  injured  side,  the  affected  shoulder 
is  depressed,  and  the  corresponding  elbow  and  forearm  are 
supported  by  the  well  hand.  The  space  between  the  neck 
and  the  outer  aspect  of  the  shoulder  is  shortened. 

Fractures  of  the  Humerus. — It  is  most  important  in  these 
fractures  to  carefully  examine  the  sensation  and  power  of 
the  arm,  forearm,  and  hand,  in  order  to  ascertain  whether 
the  fracture  has  involved  the  musculospiral  nerve.  The 
characteristic  wrist   drop   follows   paralysis   of  this   nerve. 


438     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

Many  a  malpractice  suit  will  be  avoided  and  many  a  patient 
will  be  prevented  from  being  dissatisfied  with  the  treatment 
he  has  received  if  he  is  told  at  the  outset  that  the  injury  he 
has  sustained  has  involved  this  nerve  and  may  be  followed 
by  paralysis  of  the  muscles  supphed  by  it.  Measurements 
of  the  humerus  should  be  made  from  the  tip  of  the  acromion 
process  to  the  external  epicondyle  of  the  humerus. 

Fractures  of  the  Radius  and  Ulna. — The  deformity  may 
be  slight,  especially  in  fat  subjects,  with  little  displacement 
of  the  fragments.  With  green-stick  fractures,  which  occur 
quite  frequently  in  these  bones  between  the  ages  of  two  and 
fourteen  years,  crepitus  is  absent  unless  one  bone  is  com- 
pletely fractured ;  the  deformity,  however,  is  very  evident. 

Fractures  of  the  coronoid  process  of  the  ulna  are  usually 
associated  with  backward  dislocation  of  the  ulna,  and  should 
be  suspected  if  the  dislocation  recurs  readily  after  reduction. 

The  fractured  process  should  be  sought  about  one  finger's 
breadth  above  the  bend  of  the  elbow;  its  palpation  may  be 
difficult,  but  its  discovery  with  the  x-ray  will  be  easy. 

Fractures  of  the  olecranon  process  result  in  an  inability  to 
forcibly  extend  the  arm;  a  depression  marks  the  separation 
between  the  fractured  ends. 

Fractures  of  the  Femur. — Shortening  is  determined  by 
measuring  from  the  anterior  superior  iliac  spine  to  the 
internal  malleolus  of  the  same  side,  the  patient  lying  flat 
upon  his  back  and  both  iliac  spines  being  on  the  same 
straight  plane. 

Fractures  of  the  Patella. — These  are  attended  with  partial 
or  complete  loss  of  power  of  extension  of  the  leg,  the  degree 
of  interference  with  this  movement  depending  upon  the 
extent  of  the  associated  tear  of  the  quadriceps  muscle.  The 
patient  is  often  unable  to  raise  the  heel  from  the  bed  when 
lying  upon  the  back.  The  knee-joint  is  distended  with 
blood. 

Fractures  of  the  Tibia  and  Fibula.— Shortening  should 
be  determined  by  measuring  from  the  internal  condyle  of 
the  femur  to  the  tip  of  the  internal  malleolus.  Fracture  of 
both  bones  is  attended  by  eversion  of  the  foot. 


CHAPTER   XLVIL 

INFLAMMATIONS  AND  NEOPLASMS  OF  BONES. 

ACUTE  OSTEOMYELITIS. 

While  the  acute  infective  bacterial  osteomyelitis  and 
periostitis  are  among  the  most  serious  and  often  rapidly 
fatal  diseases  which  the  surgeon  is  called  upon  to  treat,  the 
acute  non-infectious,  non-bacterial  periostitis  and  osteomy- 
elitis never  threaten  life  or  limb,  and  never  provoke  anything 
but  the  mildest  constitutional  manifestations.  The  former 
are  rapidly  destructive  and  eminently  septic  inflammations ; 
they  follow  an  infection  of  the  medullary  canal  and  perios- 
teum by  the  pyogenic  bacteria,  most  commonly  the  staphylo- 
coccus aureus,  which  are  carried  to  the  bone  by  the  blood 
from  other  foci  of  suppuration  (most  frequently  from  furun- 
cles, from  the  intestines,  air  tubes,  etc.),  or  are  directly 
introduced  through  open  wounds.  The  latter  is  a  repara- 
tive process  and  is  seen  after  fractures,  aseptic  bone  inju- 
ries, etc. 

In  no  other  surgical  affection  is  it  so  essential  to  make  an 
early  diagnosis  and  rapidly  institute  the  proper  treatment 
as  in  the  acute  bacterial  forms  of  osteomyelitis.  In  many 
instances  the  integrity  of  the  limb  and  the  very  life  of  the 
patient  depend  upon  an  immediate  opening  and  drainage  of 
the  infected  medullary  canal,  and  only  too  often  does  it 
occur  that  extensive  bone  necrosis  and  severe,  even  fatal, 
septicaemia  ensue,  even  though  a  diagnosis  has  been  promptly 
made  and  the  proper  procedures  rapidly  carried  out. 

The  disease  occurs  at  any  period  of  life,  but  is  especially 
frequent  during  childhood  and  adolescence.  In  the  fou- 
droyant  cases  the  patients  are  from  the  outset  intensely  ill. 
The  constitutional  symptoms  are  those  of  a  severe  intoxi- 
cation— viz.,  extreme  prostration,  delirium,  high  fever,  105° 


440     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

to  106°;  rapid  pulse,  120  to  150,  and  dry  tongue;  the  local 
symptoms  are  very  slight  or  are  not  at  all  in  evidence.     After 


Fig.  161 

*^ 

|?f|f»8pe 

"^^ig^-i^ 

msm 

^^^^^H    ^^^^^m^B 

■ 

p 

Acute  osteomj-elitis  of  the  femur,  due  to  the  streptococcus  pyogenes,  with  sero- 
purulent  gonitis.  Note  the  swelling  of  the  affected  limh  and  the  periarthritis  at  the 
knee. 

twenty-four  or  forty-eight  hours  these  patients  die  or  the 
constitutional  symptoms  ^  abate  somewhat,  owing  to  spon- 
taneous perforation  of  the  bone  and  periosteum;  the  local 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     441 

manifestations  then  become  more  evident  and  palpable.  In 
this  class  of  cases  the  septicaemia  commences  with  the  osteo- 
myelitis. The  clinical  phenomena  are  due  to  the  blood  poison- 
ing, which  overshadows,  both  in  its  importance  and  in  its 
manifestations,  the  local  bone  disease  which  has  been  its 
cause.  In  some  of  the  patients  the  local  evidences  afforded 
by  the  diseased  bone — viz.,  pain,  swelling,  and  a  limited  use 
of  the  affected  limb — may  not  have  had  time  to  develop 
before  death  occurred. 

In  the  moderately  severe  cases  (which  constitute  the  largest 
number)  the  onset  of  the  disease  is  attended  by  a  chill,  to 
which  follow  a  continuously  high  fever,  rapid  pulse  rate, 
coated,  dry  tongue,  drowsiness,  mild  delirium  and  constantly 
high  leukocytosis  (20,000  or  over).  Over  the  infected  bone 
the  soft  parts  become  considerably  swollen,  oedematous,  and 
exquisitely  painful  and  tender;  active  motion  is  suspended 
and  passive  motion  is  attended  with  excruciating  pain.  If 
the  infection  is  at  the  epiphyseal  end  of  the  bone  the  neigh- 
boring joint  becomes  coincidently  involved;  at  first  the  peri- 
articular structures  become  oedematous,  then  a  serous  or  sero- 
purulent  exudate  forms  within  the  capsule  of  the  joint,  and 
if  infection  of  the  joint  cavity  occurs,  a  purulent  arthritis 
develops.  If  no  relief  is  afforded  by  surgical  means,  the 
patient,  usually,  succumbs  to  blood  poisoning;  in  some 
instances  the  life  of  the  patient  is  saved  by  spontaneous 
perforation  of  the  bone  and  periosteum.  The  perforation  is 
followed  by  the  formation  of  an  abscess  in  the  soft  parts 
which  occasions  increased  swelling  and  redness.  An 
abscess,  however,  is  not  always  to  be  construed  as  an  evi- 
dence of  a  perforation  of  the  bone;  in  many  instances  it  is 
due  to  the  breaking  down  of  an  infected  vascular  thrombus, 
or  to  suppuration  of  the  lymphatic  vessels  or  glands.  With 
perforation  of  the  bone  the  constitutional  symptoms  regu- 
larly subside  in  intensity  because  the  tension  of  the  inflam- 
matory products  within  the  medullary  canal  is  thereby 
relieved. 

The  cases  in  which  the  local  symptoms  are  present  in 
conjunction  with  high  fever,  rapid  pulse,  drowsiness,  and 
coated,  dry  tongue  are  easily  recognized;  but  in  the  foudroyant 
cases,  and  in  the  very  early  stages  of  the  less  severe  cases 


442     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

before  the  local  signs  have  fully  developed,  the  diagnosis  is 
not  so  easy,  and  yet  it  is  in  these  septic  cases  that  it  is  most 
necessary  to  make  an  early  diagnosis  and  promptly  institute 
the  proper  methods  of  treatment.  A  good  working  rule  is 
the  following:  Every  child  and  young  adult  in  whom  there 
is  a  sudden  onset  of  high  fever,  rapid  pulse,  etc.,  for  which 
no  adequate  cause  can  be  found,  should  be  suspected  of 
being  afflicted  with  an  acute  infectious  osteomyelitis,  and 
for  the  presence  of  this  malady  every  bone,  and  especially 
its  epiphyseal  ends,  should  be  carefully  examined.  A  child 
may  be  too  sick  to  complain  of  local  pain,  and  in  the  absence 
of  swelling,  redness,  etc.,  the  existence  of  a  bone  disease 
may  not  be  suspected.  It  is  the  author's  experience  that 
even  delirious  and  comatose  patients  manifest  by  a  shriek 
or  a  cry  or  by  restlessness  an  exquisite  tenderness  over  an 
infected  bone,  and  that  this  tenderness  is  present  before 
swelling  and  oedema  have  become  evident.  This  tenderness, 
taken  in  conjunction  with  the  constitutional  symptoms  for 
which  on  careful  examination  no  other  adequate  cause  can 
be  found,  forms  a  most  valuable  early  indication  of  the  pres- 
ence of  an  acute  septic  osteomyelitis;  in  the  later  stages  of 
the  malady,  when  the  entire  affected  limb  has  become  much 
swollen,  the  location  of  the  acute  pain  enables  the  examiner 
to  accurately  determine  the  site  of  the  disease. 

The  other  constitutional  diseases,  which  in  their  onset 
resemble  acute  infectious  osteomyelitis,  are  typhoid  fever, 
cerebrospinal  meningitis,  and  miliary  tuberculosis. 

In  typhoid  fever  the  leukocyte  blood  count  is  low,  the  pulse 
is  slow;  there  may  be  a  Widal  reaction.  The  Ehrlich  diazo- 
reaction  in  the  urine  may  be  present  in  both  affections. 

In  cerebrospinal  meningitis  the  neck  is  very  apt  to  be 
rigid,  Kernig's  sign  is  present,  the  pulse  is  slow,  the  leuko- 
cyte count  is  not  apt  to  be  as  high,  and  lumbar  puncture 
yields  a  turbid  fluid  containing  bacteria,  usually  the  diplo- 
coccus  or  streptococcus. 

In  miliary  tuberculosis  careful  search  will  reveal  in  the 
glands  or  in  the  lungs  or  bones  a  primary  focus  of  the  disease. 
Furthermore,  the  leukocyte  count  is  not  apt  to  be  so  high, 
the  temperature  curve  is  irregular,  the  respirations  are 
frequent,  and  tubercles  may  be  found  on  the  choroid. 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     443 

Subacute  types  of  epiphysitis  occur,  in  which  the  distention 
of  the  neighboring  joint  by  a  viscid  catarrhal  fluid  forms 
the  chief  symptom,  the  constitutional  manifestations  being 
very  mild.  Such  conditions  of  the  joints  have  been  styled 
"Volkmann's  catarrhal  synovitis."  They,  as  well  as  the 
more  acute  forms  of  joint  manifestations  that  attend  acute 
infectious  epiphysitis  and  osteomyelitis,  must  be  differ- 
entiated from  the  rheumatic  forms  of  synovitis.  The  latter 
are  not  as  frequently  met  with  in  children;  their  onset  is  not 
so  severe,  nor  their  course  so  rapid;  they  are  frequently 
preceded  by  tonsillitis,  and  are  more  apt  to  be  polyarticular. 
Furthermore,  the  arthritides  complicating  epiphysitis  and 
osteomyelitis  are  always  associated  with  periarthritis,  whereas 
with  the  rheumatic  joints  there  is  no  periarthritis  at  all,  and 
there  is  no  local  tenderness  over  the  bone. 

It  is  doubtful  whether  the  metastatic  joint  lesions  following 
the  acute  exanthemata  are  not  due  to  a  primary  metastatic 
osteomyelitis,  the  joint  symptoms  being  the  most  striking 
manifestation.  A  primary  pyarthrosis  occurring  in  these  dis- 
eases is  to  be  distinguished  from  the  joint  lesions,  which  are 
secondary  to  bone  involvement,  by  the  absence  of  bone  ten- 
derness, and  by  the  previous  history  of  an  eruptive  disease. 

The  joint  lesions  due  to  gonorrhoea  are  to  be  distinguished 
from  those  which  are  secondary  to  acute  osteomyelitis  by 
their  greater  frequency  in  young  adult  males,  by  the  presence 
of  a  urethral  discharge  or  shreds  in  the  urine,  by  the  con- 
siderable periarthritis  that  attends  them,  by  the  absence  of 
tenderness  over  the  epiphyses,  and  by  the  less  severity  and  less 
rapid  development  of  the  constitutional  symptoms. 

It  is  to  be  especially  noted  that  a  joint  effusion,  together 
with  periarthritis,  may  precede  the  development  of  the  other 
local  evidences  of  acute  osteomyelitis. 

Some  forms  of  acute  tuberculous  arthritis  in  infancy  resemble 
acute  osteomyelitis  with  joint  complications.  The  joint  is 
hot,  swollen,  and  sensitive,  the  onset  is  sudden,  and  the 
constitutional  symptoms  severe.  Such  cases  are  usually 
observed  in  children  whose  mothers  suffer  from  advanced 
disease  of  the  lung. 


444     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 


CHRONIC  INFLAMMATIONS  OF  BONE. 

Severe,  rapidly  progressing,  and  destructive  as  are  the 
acute  infective  forms  of  osteomyelitis,  so  chronic,  slow,  and 
function-disturbing  are  the  chronic  types  of  this  malady. 
They  commence  insidiously  or  acutely  and  then  subside 
into  a  chronic  stage,  progress  slowly  and  steadily,  or  lie 
dormant  for  months  and  years,  and  flare  up  at  times  in 
acute  exacerbations.  They  cause  a  gradual  impairment  in 
the  general  health,  and  when  attended  with  prolonged  sup- 
puration they  give  rise  to  waxy  degeneration  of  the  internal 
viscera.  They  likewise  result  in  a  gradually  increasing 
impairment  of  the  functional  activity  of  the  diseased  limb. 

The  most  common  varieties  of  chronic  osteomyelitis  are 
the  pyogenic  (the  invading  organisms  being  of  diminished 
virulence),  the  typhoidal,^  the  tuberculous,  the  syphilitic,  and 
the  actinomycotic. 

The  local  evidences  of  chronic  bone  disease  are,  as  a  rule, 
well  marked  and  readily  recognized.  The  patients  complain 
of  pain  and  tenderness  in  the  diseased  bone;  the  pain  is 
deep  seated,  intense,  boring  or  gnawing  in  character,  often 
intermittent,  and  generally  most  severe  after  exposure  to 
cold,  after  active  exercise  or  when  the  patient  retires  to 
bed  and  the  limb  becomes  warm;  the  tenderness  is  circum- 
scribed and  corresponds  to  the  site  of  the  disease.  The 
physical  evidences  may  be  very  slight  in  the  early  stages  of 
the  disease,  but  they  become  more  marked  with  its  develop- 
ment. If  the  malady  is  confined  to  the  medullary  cavity 
the  bone  feels  uniformly  thickened  and  enlarged;  if  the 
periosteum  is  also  involved  the  bone  is  irregularly  thickened 
and  its  surface  is  uneven  and  of  varying  consistency,  harder 
in  some  places,  softer  in  others.  In  some  instances  an  exu- 
date forms  between  the  periosteum  and  the  bone.  The  soft 
parts  overlying  the  diseased  bone  may  be  normal  or  thick- 
ened, or  adherent  to  the  bone,  or  infiltrated,  or  the  seat  of 
abscesses.  The  pus  in  the  abscesses  may  burrow  by  gravity 
along  the  planes  of  least  resistance  to  distant  points,  and 

1  When  the  Eberth  bacillus  produces  suppuration  it  probably  has  changed  its  spe- 
cific character  and  become  a  pyogenic  organism. 


PLATE   IX. 


Chronic  Osteoperiostitis  of  the  Tibia. 

Note  the  thickening  of  the  periosteum,  the  deeper  shadow  of  the  cortical 
tissue  of  the  tibia,  and  the  irregular,  shaggy  projections  from  the  perios- 
teum of  the  tibia      Compare  with  the  picture  of  the  healthy  fibula  alongside. 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     445 

perforate  on  to  the  skin  with  the  formation  of  sinuses  and 
fistulse.  Such  sinuses  always  lead  down  to  necrotic  or  carious 
bone.  The  appearance  of  the  fistulse  and  the  character  of 
their  discharge  depend  on  the  nature  of  the  disease  in  the 
bone.     (See  below.) 

The  functional  disturbances  which  are  occasioned  by  these 
forms  of  osteomyelitis  depend  chiefly  on  the  location  of  the 
diseased  process.  Where  the  inflammation  is  limited  to  the 
shaft  of  the  bone  the  interference  with  function  is  usually 
very  slight;  at  times,  however,  the  boring  pain  and  tender- 
ness restrict  the  active  use  of  the  limb,  though  passive 
motion  remains  normal;  those  movements  are  especially 
restricted  which  are  performed  by  muscles  whose  place  of 
insertion  on  the  bone  corresponds  to  the  site  of  the  disease. 
When  the  articular  end  of  the  bone  is  involved,  as  is  most 
frequently  the  case  in  the  tuberculous  forms  of  the  disease, 
active  and  passive  movements  of  the  corresponding  joints 
are  restricted.  It  is  to  be  noted  that  such  restriction  may 
not  be  in  evidence  in  all  of  the  movements  which  the  joint 
normally  enjoys.     (See  Tuberculous  Joint  Disease.) 

After  long  continuance  of  the  disease,  especially  if  it  is 
attended  with  suppuration,  the  general  health  suffers;  the 
individual  becomes  pale,  anaemic,  and  thin,  may  sweat  at 
night,  has  occasional  elevations  of  temperature,  loses  his 
appetite,  and  in  the  final  stages  waxy  degeneration  of  the 
internal  viscera,  of  the  kidneys,  liver,  spleen,  etc.,  develops.^ 

The  x-ray  affords  valuable  clinical  data  for  the  diagnosis 
and  differentiation  of  chronic  bone  disease,  and  as  greater 
experience  is  obtained  in  the  interpretation  of  the  pictures  it 
affords  more  aid  from  its  use  can  be  expected.  In  the 
shadowgraphs  note  should  be  taken  of  changes  in  the  outline 
and  thickness  of  the  bone  and  its  periosteum,  of  the  structure 
of  the  cancellous  tissue,  and  of  the  amount  of  rays  which 
are  absorbed  by  the  tissues.  No  radiograph  is  good  unless 
it  shows  the  details  of  the  bones  and  of  the  soft  parts. 
When  the  periosteum  is  diseased  it  appears  thickened,  its 
under  surface  being  irregular,  with  shaggy  projections  here 

1  It  is  always  most  important  to  ascertain  whether  the  internal  viscera  are  healthy 
before  a  prognosis  is  made  in  cases  of  chronic  bone  disease. 


446     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

and  there;  the  bone  shadow  is  darker  in  osteosclerotic  areas 
and  Ughter  in  the  osteoporotic  parts.     Sequestra  are  recog- 


FlG, 162 


^^^m^mm-                 -  r-y^mg^^^^^ 

^^^_ 

^^^^^— 

1 

1 

[ 

1 

^^■'v^^ 

^ 

1 

L^ 

\ 

r^^^P 

^r       i^BplM         KH^ 

1 

i 

1 

'  iiiJH^'-'il 

^ 

II^B 

l] 

Chronic  osteoma  of  the  right  tibia  (recurrent).  Note  the  difFuse  swelling  and  thick 
ening  of  the  right  leg,  which,  together  with  the  history  of  repeated  acute  exacerba- 
tions of  the  malady,  readily  permitted  us  to  make  the  diagnosis  of  chronic  pyogenic 
osteomyelitis. 


PLATE  X. 


Chronic  Osteomyelitis  of  the  Tibia,  >A^ith  Sequestra 
Formation. 

The  lightest  areas  correspond,  to  the  cavities  in  the  bone  \vhieh  eon- 
tain  the  sequestra.  The  slightly  darker  shadows  correspond  to  the  osteo- 
porotic bone,  and  the  darkest  shadows  represent  the  osteosclerotic  portions 
of  the  bone.  A  sinus  leading  down  to  a  sequestrum  is  visible  in  the  upper 
part  of  the  picture. 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     447 

nized  as  light  shadows  lying  in  a  still  lighter  area,  which 
latter  corresponds  to  the  cavity  containing  the  sequestrum. 
The  reading  of  the  radiograph  correctly  demands  consider- 
able experience;  the  picture  of  the  healthy  part  should 
always  be  read  in  conjunction  with  that  of  the  diseased 
side. 

In  a  well-marked  case  of  chronic  bone  disease  little 
difficulty  should  be  experienced  in  making  the  diagnosis. 
The  spontaneous,  intense,  boring  pain;  the  local  tenderness, 
the  changes  in  the  contour  and  thickness  of  the  bone,  the 
abscesses  in  the  soft  parts,  and  the  presence  of  sinuses  and 
fistulse  leading  down  to  carious  or  necrotic  bone  clearly 
indicate  the  disease  which  is  present.  But  easy  as  it  is  to 
make  the  diagnosis  in  the  fully  developed  cases,  so  difficult 
is  it  often  in  the  initial  stages.  In  children  who  are  the  most 
frequent  sufferers  from  this  form  of  bone  disease  the  slight 
functional  disturbances  which  are  present  in  the  early  stages 
of  the  disease  are  often  ascribed  to  a  fall  or  trauma;  on 
cross-questioning,  however,  we  will,  as  a  rule,  ascertain  that 
the  trauma  was  very  slight  and  not  sufficient  to  account  for 
the  symptoms,  and  frequently  we  will  find  that  the  trau- 
matism was  not  really  noticed  by  the  parent,  but  only  sub- 
sequently thought  of  in  order  to  account  for  the  little 
patient's  trouble.  One  sign  is  pathognomonic  of  early  bone 
disease  when  it  is  located  at  the  epiphyseal  ends,  and  that 
is  restricted  movements  of  the  adjacent  joint  in  one  or  more 
directions,  the  limitation  of  movement  being  attended  with 
a  reflex  muscular  spasm.  Continued  use  of  the  rr-ray  and 
careful  study  of  the  pictures  which  it  gives  may  in  the  future 
help  us  considerably  in  the  early  diagnosis  of  chronic  bone 
disease. 

The  nature  of  a  chronic  bone  inflammation  is  determined 
from  a  study  of  the  anamnesis  and  from  the  especial  char- 
acteristics of  the  local  lesion.  The  family  and  personal  past 
history  of  the  patient  and  other  evidences  of  a  constitutional 
disease  may  furnish  us  with  valuable  data  for  this  determi- 
nation. Thus  a  history  of  a  previous  attack  of  acute  osteo- 
myelitis in  the  same  bone,  or  in  another  bone,  or  of  recurrent 
exacerbations  of  the  chronic  inflammation,  points  very 
strongly  to  a  chronic  pyogenic  osteomyelitis.     If  the  disease 


448     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

is  located  at  the  diaphyseal  end  of  one  of  the  long  bones, 
and  commenced  acutely  or  subacutely  with  moderate  fever 
and  pain,  which  subsided  after  a  few  days,  and  if  its  subse- 
quent course  was  characterized  by  a  very  gradual  but  con- 
siderable cystic  swelling  of  the  periosteum  and  bone  from 


Fig.  163 


Spina  veutosa.    Note  the  swelling  of  the  fingers,  due  to  distention  of  the  medullary 
canal  of  the  phalangeal  bones  by  tuberculous  tissue. 

an  accumulation  of  synovial-like,  mucoid  material  between 
the  bone  and  periosteum,  or  in  the  periosteum,  or  external 
to  it,  it  is  very  likely  to  be  a  periosteo-osteomyelitis  alhuminosa 
(Oilier) — {.  e.,  a  subacute,  serous  osteomyelitis;  such  an 
inflammation  is  due  to  bacteria  of  diminished  virulence. 
If  the  disease  is  very  chronic  and  is  located  at  the  epi- 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     449 

physeal  ends  of  the  long  bones ;  if  there  are  abscesses  in  the 
soft  parts  which  on  aspiration  yield  a  yellowish,  flocculent 
material,  and,  further,  if  there  are  worm-eaten,  cheesy,  under- 
mined, retracted,  fistulous  openings  which  lead  down  to  bare 
carious  bone,  and  from  which  a  cheesy,  flocculent  material 
is  discharged,  it  is  tuberculous  in  character.  Occasionally  the 
medullary  canal  is  much  distended  by  the  tuberculous 
deposit  within  it,  and  its  cortex  is  consequently  thinned  and 
expanded.  The  spina  ventosa  most  frequently  seen  in  the 
phalanges  of  the  fingers  are  examples  of  such  lesions. 

If  there  is  a  previous  history  of  syphilis  and  if  there  are 
in  the  periosteum  one  or  more  flat,  elastic  swellings,  which 
contain  a  fatty,  cheesy,  somewhat  purulent  material,  the 
disease  is  syphilitic;  these  lesions  are  styled  gummata.  Under 
antisyphilitic  treatment  these  swellings  shrink  into  firm, 
fibrous  nodes.  Such  periosteal  swellings  are  especially 
frequent  in  the  cranial  bones  and  clavicle,  but  they  are  rare 
in  the  diaphyses  of  the  long  bones. 

Gummata  of  the  bone  itself  form  nodes  varying  in  size 
from  a  lentil-seed  to  a  nut.  They  are  single  or  multiple, 
and  may  remain  unrecognized  until  spontaneous  fracture 
takes  place;  this  occurrence,  together  with  a  history  of 
syphilis  and  the  absence  of  a  distinct  neoplasm,  should 
enable  us  to  make  the  diagnosis. 

A  previous  history  of  syphilis  with  hypertrophy  and 
irregular  nodulation  and  sclerosis  of  the  bone  is  indicative 
of  a  syphilitic  ossifying  osteoperiostitis. 

The  picture  of  rachitis  with  a  congenital  luetic  history 
suggests  syphilis  as  a  cause  of  the  rachitical  symptoms. 

If  the  bone  symptoms  develop  during  the  course  of  or 
during  the  convalescence  from  typhoid  fever  and  are  sub- 
acute in  character,  the  process  is  in  all  probability  due  to 
the  typhoid  bacillus.  It  usually  commences  at  those  portions 
of  the  bone  to  which  the  muscles  are  attached. 

Benign  and  malignant  neoplasms  of  bone  give  rise  to  pain, 
local  tenderness,  thickening,  and  hypertrophy  of  the  bone, 
and  so  resemble  the  chronic  inflammatory  conditions.  The 
enlargement  which  is  due  to  periosteal  or  cortical  neoplasm, 
however,  is  circumscribed;  it  commences  abruptly,  whereas 
that  due  to  chronic  inflammation  is  diffuse  and  more  irregular. 

29 


450     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

Central  sarcomata  occasion  a  diffuse  enlargement  of  the  bone, 
and  are  to  be  differentiated  from  inflammatory  affections  by 
their  rapid  growth,  by  the  absence  of  previous  inflammatory, 
syphilitic  or  tuberculous  history,  and  by  the  egg-shell  crackle 
of  the  thinned-out  cortical  tissue  over  the  tumor.  The  x-ray 
often  aids  in  the  differentiation  of  these  cases. 

In  a  number  of  cases,  however,  it  is  impossible  to  decide 
upon  the  exact  nature  of  the  swelling  of  the  bone  prior  to 
its  exposure  and  microscopic  examination.  It  is  well  to 
consider  every  doubtful  neoplastic  swelling  as  syphilitic 
until  a  lack  of  improvement  thereof  from  antispecific  treat- 
ment has  proven  it  not  to  be  so. 


NUTRITIVE  DISEASES  OF  BONES. 

A  local  malnutrition  of  bone  with  consequent  atrophy  and 
fragility  thereof  accompanies  disease  of  contiguous  joints, 
while  nutritive  disturbances  of  a  number  or  all  of  the  skeletal 
bones  are  dependent  upon  some  constitutional  disease,  such  as 
rickets,  osteomalacia,  fragilitas  ossium,  and  osteitis  deformans. 

Rachitis. — ^Rachitical  disease  occurs  in  insufficiently  or 
improperly  fed  children  and  in  those  who  suffer  from  gastro- 
intestinal diseases  with  consequent  impaired  digestion,  ab- 
sorption, and  assimilation.  It  is  readily  recognized  from  the 
changes  it  occasions  in  the  osseous  system;  these  include  a 
softening  of  the  cranial  bones  (craniotabes),  a  delayed  closure 
of  the  fontanelles,  a  broadening  of  the  anterior  portion  of  the 
skull,  an  enlargement  at  the  chondrocostal  junction  (the  latter 
forming  the  rachitical  rosary),  a  flattening  of  the  chest,  and 
tender,  enlarged  epiphyseal  ends  of  the  long  bones,  with 
relaxation  of  the  joint  ligaments,  thus  permitting  of  abnormal 
mobility  of  the  joints.  As  the  children  grow  older  spinal 
curvature,  bow-legs,  genu  valgum  or  varum,  bear  testimony 
to  the  past  or  present  existence  of  rachitical  disease. 

Osteomalacia. — Osteomalacia  occurs  chiefly  in  pregnancy 
or  nursing  women,  though  it  is  met  with  in  men  and  in  non- 
puerperal women.  In  the  former  it  starts  in  the  pelvic  bones, 
in  the  latter  in  the  spinal  column  and  bones  of  the  chest. 
The  disease  is  readily  recognized  from  the  softening,  bending, 


Periosteal  Sarcoma  of  the  Fibula. 

Note  the  spindle-shaped  enlargement  of  the  upper  end  of  the  bone  ; 
there  is  no  thinning  out  of  the  cortical  tissue  and  no  involvement  of  the 
medulla  by  the  neoplasm.  Note  the  sniooth  surface  of  the  periosteum  and 
compare  with  Plate  IX. ,  of  inflammatory  osteoperiostitis.  This  tumor  gave 
rise  to  a  metastatic  sarcoma  of  the  brain.  It -was  unnoticed  by  the  patient, 
"who  came  to  the  hospital  for  his  cerebral  condition. 


PLATE  XII. 


y 

^ 

■ 

^^H 

r     ^fhn 

^ 

\ 

1 

I 

ii9^^^^v 

^ 

^^^ 

1 

^^H 

wmt 

i:  X  .^ 

i 

^H 

E 

BB^m 

te 

J 

Sarcoma  of  the  Leg,  on  the  basis  of  an  old  varicose  vxlcer  of 
the  leg.     Note  character  of  the  ulcer. 


Raynaud's  Disease,  with  Gangrene  of  Second  Toe      Note  that  the  big 
toe  on  the  other  foot  is  also  partly  missing  from  gangrene. 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     451 

and  spontaneous  fracture  of  the  bones  which  it  occasions. 
The  wandering  pains  in  the  bones,  which  attend  the  early 
stages  of  the  disease,  may  suggest  rheumatism,  but  the  latter 
is  readily  excluded  by  the  absence  of  joint  involvement. 
From  rachitis  it  is  differentiated  by  the  infrequency  with 
which  the  cranial  bones  are  involved,  while  the  spontaneous 
fractures  to  which  it  gives  rise  are  differentiated  from  those 
due  to  malignant  disease  by  their  multiple  character  and  the 
absence  of  a  tumor. 

Osteitis  Deformans. — Osteitis  deformans  is  characterized 
by  its  development  in  middle  life  or  later,  the  symmetrical 
distribution  of  the  lesions,  its  very  slow  progress,  and  its 
predilection  for  the  long  and  cranial  bones.  The  affected 
bones  become  enlarged  and  softened,  in  virtue  of  which  they 
yield  and  bend. 

Exostoses. — Exostoses  may  likewise  be  looked  upon  as 
disturbances  of  nutrition.  Their  favorite  sites  are  the 
epiphyseal  ends  of  the  long  bones,  especially  the  inner  surface 
of  the  femur  just  above  the  condyles,  the  head  of  the  tibia, 
and  the  phalanges  of  the  fingers  and  toes.  They  are  often 
multiple  and  their  surface  is  irregular. 


NEOPLASMS  OF  BONE. 

Benign  tumors,  of  which  the  osteoma,  chondroma,  and 
fibroma  are  the  chief  types,  develop  either  from  the  peri- 
osteum or  from  the  epiphyseal  cartilages. 

The  fibromata  originate  from  the  periosteum  and  form  hard, 
strictly  circumscribed,  painless,  very  slowly  growing  tumors. 
The  jaw-bones  are  the  favorite  sites  of  these  tumors,  and 
in  this  situation  they  go  under  the  name  of  fibrous  epules. 

The  chondromata  usually  start  from  beneath  the  periosteum 
of  the  long  bones  independent  of  the  epiphyseal  cartilage, 
and  form  firm,  lobulated,  encapsulated  tumors,  which  are 
painless  unless  they  press  upon  nerve  trunks.  They  may 
extend  into  the  medullary  canal  and  cause  expansion  of  the 
bone,  or  they  may  cause  erosion  of  the  bone  with  resulting 
spontaneous  fracture.  The  chondromata  growing  from  the 
smaller  bones  (most  usually  those  of  the  hand)  are  frequently 


452     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

multiple  and  commence  in  the  interior  of  the  bone  close  to 
the  epiphyseal  cartilage  and  cause  its  expansion. 

Osteomata  are  usually  met  with  near  the  articular  end  of 
the  bone,  forming  pedunculated  or  sessile  tumors,  often  of 
large  size.  They  start  to  develop  during  youth,  and  as  the 
bones  grow  their  base  of  attachment  may  become  separated 
from  the  epiphysis  to  an  extent  corresponding  to  the  amount 
of  growth  which  has  taken  place.  As  a  rule  the  growth  of  the 
tumor  ceases  at  maturity.  Their  most  common  sites  are  the 
inner  condyle  of  the  femur  close  to  the  adductor  tubercle,  and 
the  inner  aspect  of  the  jaw.  Ivory  exostoses  develop  most 
frequently  on  the  inner  or  outer  aspects  of  the  cranial  bones. 

All  benign  tumors  are  of  slow  growth,  encapsulated  and 
painless,  except  when  they  press  upon  nerve  trunks.  Malig- 
nant tumors,  on  the  contrary,  are  of  rapid  growth,  somewhat 
painful,  not  encapsulated,  and  frequently  lead  to  erosion  of 
the  cancellous  tissue  with  resulting  spontaneous  fracture. 

The  my xo fibromata  form  a  mid-class  between  the  benign 
and  malign  tumors.  They  grow  rather  rapidly,  are  some- 
what painful,  and  tend  to  relapse  locally  after  removal. 
They  do  not  break  down  and  ulcerate,  and  do  not  give  rise 
to  metastases  in  the  other  organs. 

Sarcomata  may  develop  either  from  the  periosteum  or  from 
the  medullary  substance.  The  periosteal  tumors  usually  start 
on  one  side  of  the  bone,  but  they  soon  surround  its  entire 
circumference  and  spread  rapidly  along  its  surface;  they  may 
be  very  vascular  and  pulsate  and  they  give  rise  to  metastases 
in  the  glands  and  internal  viscera.  The  superficial  cutaneous 
veins  in  the  skin  overlying  the  tumor  are  dilated.  The 
medullary  sarcomata  usually  commence  near  the  end  of  one 
of  the  long  bones,  but  seldom  encroach  on  the  articular 
cartilage  or  joint;  they  gradually  expand  the  surrounding 
cancellous  tissue,  thinning  it  out  and  causing  it  to  crackle 
when  it  is  palpated  (the  egg-shell  crackle),  and  frequently 
cause  spontaneous  fracture. 

The  round  and  spindle-celled  medullary  sarcomata  are  of 
very  rapid  growth  and  give  rise  to  metastases;  the  giant- 
celled  ones,  most  frequently  situated  on  the  lower  ends  of 
the  femur  and  radius,  the  upper  ends  of  the  tibia  and  humerus, 
the  horizontal  ramus  of  the  lower  jaw  and  in  the  diploe,  are 


INFLAMMATIONS  AND  NEOPLASMS  OF  BONES     453 

of  very  slow  growth,  frequently  encapsulated,  never  give  rise 
to  metastases,  and  do  not  spread  along  the  bone. 

Carcinomata  of  the  bones  are  always  metastatic  tumors. 
The  first  indication  of  their  presence  is  often  a  spontaneous 
fracture,  or  severe  shooting  pains  in  the  affected  region. 

Fig.  164 


Sarcoma  of  the  right  scapula. 

As  a  rule,  no  difficulty  is  experienced  in  distinguishing 
between  the  enlargement  of  bone  due  to  chronic  inflam- 
mation and  that  due  to  neoplasm,  for  with  the  former  the 
enlargement  is  much  more  diffuse  and  irregular,  and  the 
history  points  to  an  infection  of  the  bone. 

Similarly  the  differentiation  between  malign  and  benign 
tumors  is  easy;  the  giant-celled  sarcomata  belong  to  a  mid- 
class  between  the  malign  and  benign  growths. 


454     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

The  enlargements  of  bone  due  to  arthritis  deformans  are 
distinguished  from  those  due  to  neoplasm  by  the  symmetrical 
distribution  of  the  lesions,  their  multiple  character,  and  by 
the  fact  that  they  usually  develop  after  middle  age. 

Pulsating  sarcomata  of  the  bones  resemble  aneurysms, 
from  which,  however,  their  incompressibility,  their  non- 
disappearance  on  compression  of  the  afferent  vessel,  and 
their  diffuse  character  serve  to  distinguish  them. 

Hydatid  Cysts  of  the  Bones. — Echinococcus  cysts  are  rare 
in  their  occurrence;  they  develop  in  the  medullary  canal, 
expand  it  and  cause  its  absorption,  with  resultant  spon- 
taneous fracture. 


CHAPTER   XLVIII. 

GENERAL    REMARKS    ON    THE    DIAGNOSIS    OF    JOINT 
INJURY  AND  DISEASE. 

The  trend  of  modern  surgery  is  toward  conservatism,  and 
while  it  aims  to  thoroughly  eradicate  what  is  diseased,  it 
strives  more  and  more  to  retain  what  is  healthy  and  preserve 
the  function  of  the  diseased  part.  In  chronic  diseases  of 
the  joints  there  is  as  yet  no  unanimity  of  opinion  as  to 
whether  this  conservative  end  is  better  attained  by  the  bloody 
or  bloodless  method  of  treatment,  but  this  much  is  acknowl- 
edged by  all — viz.,  that  either  method  will  achieve  its  best 
results  if  the  disease  is  recognized  early  and  treatment 
immediately  instituted. 

The  diagnosis  of  the  acute  inflammatory  joint  diseases  is 
not  difficult,  for  the  local  lesions  and  the  constitutional 
symptoms  clearly  indicate  the  nature  of  the  malady.  Simi- 
larly the  presence  of  traumatic  lesions  is  readily  recognized, 
though  until  the  x-ray  enabled  us  to  view  the  articular 
structures  it  was  often  impossible  to  determine  their  exact 
character.  The  recognition  of  chronic  joint  disease,  espe- 
cially in  its  initial  stages,  is,  on  the  other  hand,  always 
difl&cult  and  calls  for  repeated,  careful,  systematic  physical, 
and  a:-ray  examination. 

The  joints  are  made  up  of  the  articular  ends  of  the  bones, 
covered  on  their  articular  surfaces  by  cartilage,  and  held 
together  by  capsular  ligaments,  which  latter  may  be  strength- 
ened by  accessory  bands  and  ligaments.  The  interior  of  the 
capsule  is  lined  by  a  synovial  membrane,  which  may  have 
diverticula  and  pouches  (bursae)  between  the  tendons  and 
muscles  passing  over  the  joints,  and  whose  function  it  is  to 
secrete  a  lubricating  fluid  for  the  articulating  bones.  Addi- 
tional cartilaginous  structures  are  present  within  some  of 
the  joints,  to  equalize  or  deepen  the  articular  surfaces.    Any 


456     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

one  or  all  of  these  structures  may  be  involved  in  disease.  The 
process  usually  starts  in  the  synovial  membrane  or  bone, 
and  either  remains  confined  to  these  structures  or  extends 
to  the  other  parts  of  the  joint,  resulting  in  a  panarthritis. 

In  dealing  with  joint  diseases  it  is  necessary  first  of  all 
to  obtain  a  good  family  and  personal  history  of  the  patient, 
especially  as  to  family  or  personal  tuberculosis,  syphilis,  or 
hemophilia.  The  mode  of  onset,  the  course  and  duration 
of  the  symptoms  should  also  be  ascertained.  The  examina- 
tion should  determine  the  contour  of  the  joint,  the  position 
in  which  the  affected  limb  is  held,  the  direction  of  its  axis, 
its  cutaneous  aspect,  the  presence  of  fluid  within  its  capsule, 
the  relation  of  its  own  bony  prominences  to  each  other  and 
to  neighboring  fixed  bony  points,  shortening  or  lengthening 
of  the  limb,  the  range  of  active  and  passive  motion  in  all 
directions,  whether  a  reflex  muscular  spasm  is  elicited  in 
passively  moving  the  joint,  and  finally  the  x-tslj  should 
determine  the  position  of  the  bones,  their  contour,  their 
density,  and  the  condition  of  the  epiphyseal  cartilage.  In 
every  detail  of  the  examination  we  should  always  compare 
the  healthy  with  the  supposedly  diseased  side. 

Contour. — The  contour  of  a  supposedly  diseased  joint  is 
very  significant.  If  an  enlargement  thereof  is  sharply 
circumscribed  and  strictly  limited  to  the  joint-capsule  it  is 
indicative  of  the  diseased  process  being  intracapsular;  but 
if,  on  the  other  hand,  the  enlargement  extends  in  a  fusiform 
fashion  up  and  down  the  limb  with  the  joint  at  its  widest 
part,  the  disease  is  no  longer  intracapsular,  but  involves  the 
periarticular  structures  as  well,  an  indication  of  a  pan- 
arthritis. 

Position. — ^The  position  in  which  a  joint  is  held  is  important. 
In  the  flexed  position  it  can  accommodate  the  largest  amount 
of  fluid  within  its  capsule,  consequently  this  is  the  position 
that  is  assumed  when  a  considerable  amount  of  exudate  is 
present  within  the  joint.  Other  factors,  such  as  destruction 
of  the  bone  with  displacement  of  the  joint  surfaces  and  reflex 
muscular  contraction  from  bone  disease,  may  account  for 
abnormal  positions  in  which  the  joint  is  held. 

Color  and  Vascularity  of  Cutaneous  Covering. — The 
color  and  vascularity  of  the  cutaneous  covering  of  a  diseased 


DIAGNOSIS  OF  JOINT  INJURY  AND  DISEASE     457 

joint  are  likewise  significant.  Thus  the  pale,  waxy,  marbled 
aspect  of  the  skin  in  tuberculosis  has  given  to  this  disease 
the  name  of  white  swelling.  With  acutely  inflamed  joints 
the  skin  is  reddened  and  hot.  The  enlargement  of  the 
cutaneous  veins  bears  testimony  to  long-standing  congestion 
of  the  part  from  chronic  inflammation  or  neoplasm. 

Atrophy. — The  atrophy  of  muscles  above  and  below  a 
joint  results  from  disuse  as  well  as  from  organic  disease  of 
the  joint.    In  hysterical  joint  affections  the  muscular  atrophy 

Fin.  165 


Contour  of  shoulder-joint  in  inflammation  of  subdeltoid  bursa. 
(Von  Bruns.) 

is  sometimes  very  great  and  this  may  mislead  us  into  thinking 
that  organic  disease  of  the  joint  is  present.  The  absence  of 
all  other  signs  of  organic  disease  will  enable  us  to  make 
the  correct  diagnosis.  Furthermore,  in  organic  joint  disease 
the  atrophic  muscles  frequently  show  the  electric  reactions 
of  degeneration;  this  never  occurs  in  hysterical  affections. 

Presence  of  Fluid. — The  presence  of  fluid  within  the 
capsule  of  the  joint  is  readily  recognized  from  the  filling  up 
and  rounding  out  ofj_the  normal  depressions  around  the  joint. 
Thus  in  the  shoulder  the  normal  curvature  is  increased  and 


458     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

the  deltoid  is  expanded  by  a  fluid  swelling  beneath  it;  this  is 
especially  noticeable  at  the  anterior  border  of  the  latter  along 
the  bicipital  groove,  and  sometimes  posteriorly,  and  in  the 
axillary  space.  Such  capsular  distention  is  distinguished 
from  distended  bursse  around  the  shoulder-joint  by  the  fact 
that  the  swelling  in  the  former  instance  is  to  be  seen  and 
felt  in  the  axilla,  and  in  front  of  and  behind  the  deltoid 
muscle,  whereas  distended  bursse  occupy  one  or  the  other  of 
these  regions. 

Fig.  166 


Olecranon  bursitis.  Note  the  central  location  of  the  swelling  and  the  normal 
hollows  on  either  side  of  the  olecranon  process.  Compare  with  Fig.  167,  of  contour 
of  elbow-joint  when  fluid  is  present  within  the  joint  capsule. 

In  the  elbow  the  hollows  on  either  side  of  the  olecranon 
and  tendon  of  the  triceps  are  replaced  by  soft,  fluid  swellings, 
the  outer  of  which  also  extends  down  to  and  masks  the  head 
of  the  radius.  It  is  readily  distinguished  from  distention 
of  the  olecranon  bursa  by  the  fact  that  in  the  latter  condition 
there  is  a  central  fluid  prominence  over  the  bone,  whereas 
in  the  former  the  swellings  are  placed  on  either  side  of  and 
above  the  bony  projection. 


DIAGNOSIS  OF  JOINT  INJURY   AND  DISEASE     459 

In  the  wrist  there  is  a  general  fulness,  both  on  the  anterior 
and  posterior  aspects  of  the  joint;  fluctuation  may  be  detected 
between  the  dorsal  tendons,  which  are  slightly  separated  and 
displaced.  It  is  distinguished  from  fluid  swellings  of  the 
tendon  sheaths  by  the  fact  of  its  strict  limitation  to  the 
neighborhood  of  the  joint,  and  by  absence  of  crepitus  that 
is  usually  to  be  felt  in  these  latter  conditions. 

Fig.  167 


Contour  ot  elbow-joint  in  distention  of  its  capsule.    Note  obliteration  of  all 
the  normal  furrows.    (Von  Bruns.) 


In  the  hip  there  may  be  a  little  fulness  in  the  gluteal 
region  or  in  the  upper  and  outer  part  of  Scarpa's  triangle. 
The  limb  is  held  in  abduction,  flexion,  and  eversion. 

In  the  knee  the  normal  hollows,  especially  those  on  either 
side  of  the  patella  and  ligamentum  patellae,  disappear. 
There  is  also  a  swelling  corresponding  to  the  subcrural 
pouch,  more  marked  on  the  inner  than  on  the  outer  side. 


460     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

and  extending  three  or  four  inches  above  the  patella.  When 
the  effusion  is  large  in  amount  the  patella  is  felt  to  float,  and 
on  crowding  down  the  fluid  from  the  subcrural  pouch  with 
the  one  hand  and  pressing  the  patella  sharply  backward  with 
the  other  it  can  be  felt  to  tap  against  the  intercondyloid 

Fig.  168 


Bilateral  distention  of  the  patella  bursa.  Note  the  central  location  of  the  swellings 
and  the  persistence  of  the  normal  furrows  to  either  side  of  the  patella.  These  char- 
acteristics distinguish  these  swellings  from  those  due  to  the  presence  of  fluid  with  the 
joint.    Compare  with  Fig.  169. 


notch  of  the  femur.  Enlargement  of  the  patella  bursa  can 
be  distinguished  from  intracapsular  joint  effusions  by  the 
central  location  of  the  swelling  that  it  occasions. 

In  the  ankle  the  hollows  between  the  tendo  Achillis  and 
the  malleoli  are  replaced  by  fluctuating  swellings,  the  dorsal 
tendons  are  displaced  forward,  and  a  fluid  swelling  appears 


DIAGNOSIS  OF  JOINT  INJURY  AND  DISEASE     461 

in  front  of  each  malleolus.  Enlargement  of  the  bursa 
beneath  the  tendo  Achillis  is  distinguished  by  the  fact  that, 
it  is  confined  to  the  back  of  the  joint. 

Fig.  169 


^HB         V             , 

MMi^ 

^^^^^^^^^^1 

;'|^H 

^^^^^Hk  *i<                n 

Ci 

1^1 

^^^^^^H^^R*         'flR 

1 

fl^i^M 

Distention  of  the  right  knee-joint  with  fluid  in  simple  inflammation.  Note  the 
absence  of  all  the  normal  furrows,  especially  those  on  either  side  of  the  patella  as 
seen  in  the  healthy  left  knee.    Compare  with  Fig.  168. 


Relation  of  Fixed  Points. — The  relation  of  fixed  points 
on  the  articular  ends  of  the  bones  to  each  other  and  neighbor- 
ing landmarks  is  important  as  an  indication  of  the  normal 
or  abnormal  position  of  the  articulating  surfaces.  These 
relations  may  be  altered  by  fracture,  or  by  dislocation,  or  by 


462     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

destructive  disease  of  the  bones  and  capsule  which  permit 
of  pathological  dislocation. 

These  relations  are  readily  ascertained  and  the  cause  of  a 
disturbance  in  their  normal  condition  is  determined  from  the 
anamnesis,  by  careful  palpation,  and  by  a;-ray  examination. 
In  the  hip  the  upper  border  of  the  great  trochanter  should 
just  touch  a  line  that  passes  from  the  anterior  superior  iliac 
spine  to  the  lowest  point  of  the  ischial  tuberosity;  furthermore, 
the  distance  of  the  anterior  margin  of  the  upper  border  of 
the  great  trochanter  from  a  line  that  passes  vertically  down- 
ward from  the  anterior  superior  iliac  spine,  the  patient  lying 
horizontally,  and  the  distance  of  the  great  trochanter  from 
the  median  line  of  the  body  should  correspond  on  both  sides. 

In  the  elbow  the  two  epicondyles  and  the  upper  border  of 
the  olecranon  should  be  on  a  straight  line  when  the  forearm 
is  extended. 

In  the  wrist  the  tip  of  the  radial  styloid  process  should 
be  a  little  lower  than  the  tip  of  the  styloid  process  of  the 
ulna. 

Measurement. — Measuring  the  length  of  a  limb  that  has 
been  injured  or  is  thought  to  be  diseased  should  always  be 
a  matter  of  routine  procedure.  If  no  tape-measure  is  at  hand, 
a  rough  but  very  good  estimate  of  the  comparative  length 
of  the  lower  limbs  may  be  obtained  by  placing  the  patient 
flat  on  his  back  on  a  level  couch  or  bed  and  then  comparing 
the  level  of  the  malleoli,  the  limbs  being  in  symmetrical 
positions.  The  more  accurate  method  is  tape-measurement. 
In  the  upper  extremity  the  measurement  should  be  made 
from  the  tip  of  the  acromion  process  to  the  tip  of  the  styloid 
process  of  the  radius ;  in  the  lower  extremity  from  the  anterior 
superior  iliac  spine  to  the  tip  of  the  internal  malleolus.  Care 
should  be  taken  that  the  disease  or  injury  is  not  bilateral — 
e.  g.,  coxa  vara,  congenital  dislocation,  etc. 

Motion. — ^The  extent  of  and  direction  in  which  active 
motion  is  possible  should  be  accurately  determined.  In  dis- 
locations active  motion  will  be  possible  only  in  the  direction 
of  the  deformity.  It  is  likewise  important  to  determine  the 
extent  of  passive  motion,  and,  in  connection  therewith,  the 
presence  or  absence  of  reflex  muscular  spasm,  a  most  im- 
portant early  sign  of  articular  disease. 


DIAGNOSIS  OF  JOINT  INJURY  AND  DISEASE     463 

The  spasm  is  usually  not  elicited  by  all  passive  move- 
ments; but  with  movements  in  certain  directions,  either  in 
flexion  or  extension,  abduction  or  adduction,  inward  or  out- 
ward rotation,  it  is  suddenly  provoked  and  further  movement 
in  that  direction  is  then  impossible. 

X-ray. — -The  ar-ray  has  added  vastly  to  our  means  for  the 
detection  of  injuries  and  diseases  of  joints,  and  especially  has 


Fig.  170 


Fig.  171 


Fig.  170. — X-ray  tracing  of  normal  knee-joint  (lateral  view),  showing  the  ossifica- 
tion nucleus  of  the  femoral  condyles.  This  is  a  fine  network  in  structure  and 
persists  up  to  the  sixteenth  year  of  life.    (Ludlolf.) 

Fig.  171. — X-ray  tracing  of  normal  knee  (anteroposterior  view),  showing  the  pro- 
tuherances  on  the  medial  aspect  of  the  inner  femoral  condyle).  These  are  present 
only  from  the  second  to  the  fifth  years  of  life.    (LudloflF.) 


it  proved  of  value  in  a  field  where  early  diagnosis  is  partic- 
ularly important — viz.,  in  tuberculous  disease.  Thus  in 
tuberculosis  of  the  knee-joint  occurring  in  children  under  five 
years  of  age  the  a;-ray  shows  in  the  initial  stages  a  diminution 
or  disappearance  of  the  normal  protuberances  which  are  to 
be  seen  on  the  bony,  cartilaginous  junctions,  especially  of 
the  internal  condyle,  an  irregular  bone  formation  on  the 


464     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

under  surface  of  the  condyles,  an  enlargement  of  the  bony 
or  ossified  parts  of  the  femoral  condyles,  tibia,  patella, 
and  fibula  head,  and  an  enlargement  and  rarefaction  of  the 
ossification  nucleus  in  the  epiphysis.  The  last  is  the  most 
valuable  because  it  can  be  seen  up  to  the  fifteenth  or  sixteenth 
years  of  life.  In  the  hip-joint  the  x-ray  does  not  afford  as 
much  information  as  is  desirable  because  of  the  thick  over- 
lying muscles.  The  joint  line,  instead  of  showing  as  a  light, 
half-moon-shaped  zone,  appears  very  dark  or  obscure  or 
shows  dim,  finger-like  projections  and  irregularities 


Fig.  172 


DIAGNOSIS  OF  JOINT  INJURY  AND  DISEASE     465 
Fig.  172  (continued). 


46 


Series  of  a;-ray  tracings  (lateral  view)  of  normal  knee-joints  (figures  a)  and  of  early 
stages  of  tuberculous  knee-joints  (figures  &),  showing  the  changes  in  the  size  of  the 
ossification  nucleus  of  the  femoral  condyles.  These  tracings  are  from  the  same  cases 
as  those  in  Fig.  173. 

There  is  no  lateral  view  of  la  and  16.  In  26,  36,  and  46  the  ossification  nucleus  is 
much  larger  than  in  the  corresponding  healthy  knee-joints.  In  46  and  56  the  ossifica- 
tion nucleus  of  the  patella  is  much  enlarged.  In  26  and  46  there  is  abnormal  irregu- 
larity on  the  under  surface  of  the  external  condyle.  These  changes  can  be  appre- 
ciated up  to  the  sixteenth  year  of  life  and  hence  are  of  value  in  the  diagnosis  of  more 
cases  of  early  knee-joint  tuberculosis  than  are  the  changes  in  the  protuberances  of 
the  inner  condyle,  for  these  latter  disappear  normally  after  the  fifth  year  of  life 
(Ludlofi".) 

30 


Fig.  173 
16  2a 


Series  of  a;- ray  tracings  (anteroposterior  view)  of  normal  knee-joint  (figures  a)  and 
of  early  stages  of  tuberculous  knee-joint  (figures  6),  showing  the  changes  which 
are  produced  in  the  protuberances  on  the  femoral  condyle,  in  the  early  stages  of 
tuberculous  disease  of  the  part.  All  the  tracings  of  the  healthy  limbs,  except  5a, 
show  more  or  less  well-marked  protuberances  on  the  medial  aspect  of  the  inner 
femoral  condyle.  In  5a  they  are  missing  because  this  is  a  tracing  of  the  knee  in  a 
child  of  seven  years  of  age,  when  the  protuberances  have  already  disappeared.  (See 
legend,  Fig.  171.)  The  tracings  of  the  diseased  knees  shows  these  protuberances 
almost  disappeared.  In  some  especially  (46)  there  are  marked  protuberances  on  the 
lower  aspect  of  the  internal  condyle  and  an  enlargement  of  the  internal  condyle 
tibial  tuberosity,  patella,  and  fibula  head.    (LudlofF.) 


CHAPTER  XLIX. 

INJURIES  OP  THE  JOINTS. 

Directly  and  indirectly  applied  traumatism,  and  irregular 
or  too  sudden  or  too  vigorous  action  of  the  muscles  attached 
to  the  bony  prominences  around  a  joint  may  occasion  a 
fracture  of  the  articular  ends  of  the  bones,  rupture  of  liga- 
ments, dislocation  of  the  joint  ends,  evulsion  of  bony  tuber- 
cles or  processes,  hsemarthrosis  or  synovitis. 

Fractures  are  characterized  by  the  same  signs  as  attend 
similar  lesions  of  the  shafts  of  bones;  dislocations  by  the 
deviation  of  the  axis  of  the  limb,  abnormal  position  of  the 
head  of  the  bone,  and  change  in  the  length  of  the  limb;  sprains 
by  pain  in  and  tenderness  over  the  joint,  some  loss  of  func- 
tion, ecchymosis  and  the  absence  of  signs  pointing  to  fracture 
or  dislocation;  synovitis  and  hoemarthrosis  by  swelling  and 
distention  of  the  capsule  and  pain  in  the  joint,  the  swelling 
being  plainly  fluctuating  in  the  former  instance  and  soft  and 
doughy  in  the  latter. 

It  would  appear  from  the  above  that  the  diagnosis  of  the 
nature  and  exact  location  of  the  lesion  is  comparatively  easy, 
and  so  it  would  be  but  for  the  obliteration  of  all  the  landmarks 
around  the  joint  which  is  occasioned  by  the  extensive  swelling 
of  the  periarticular  structures  and  for  the  excruciating  pain 
that  usually  renders  examination  of  the  parts  without  the  aid 
of  an  anaesthetic  exceedingly  difficult.  The  a:-ray  has  materi- 
ally aided  our  diagnostic  resources  and  at  the  present  day  no 
joint  lesion  should  be  treated  without  its  employment.  In 
making  an  examination  of  an  injured  joint  we  should  always 
compare  the  supposedly  healthy  side  with  the  injured  one. 

CLINICAL    AND    DIAGNOSTIC    FEATURES    OF    THE 
INJURIES  OF  THE  LARGE  JOINTS. 

Shoulder-joint. — In  the  examination  of  an  injured  shoulder 
it  is  important  to  note  the  contour  of  the  joint  (whether  it 
is  rounded  or  flattened),  the  direction  of  the  axis  of  the 


468     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

limb,  the  presence  of  any  deformity,  the  position  of  the  head 
of  the  humerus  in  reference  to  the  gleniod  cavity,  and 
whether  the  humeral  head  moves  with  the  shaft. 

With   the   most   common   form    of  dislocation   the  sub- 
coracoid,  the  patient's  attitude  is  characteristic.    The  affected 


Fig. 174 


Subcoracoid  dislocation  of  the  humerus.  Note  the  flattening  of  the  shoulder,  the 
position  of  the  arm  and  forearm,  and  the  position  of  the  head  of  the  humerus  in  rela- 
tion to  the  other  bony  landmarks.    (Hofifa.) 

forearm  is  held  flexed  with  the  elbow  away  from  the  side 
and  the  arm  rotated  inward.  The  anterior  axillary  fold  is 
lowered;  the  long  axis  of  the  humeral  shaft  is  inclined 
inward;  the  shoulder  is  flattened;  the  acromion  process  is 
prominent.  The  head  of  the  humerus  is  out  of  the  glenoid 
cavity;  it  rotates  with  the  shaft,  and  most  often  lies  under  the 


PLATE  XIII. 


Subeoracoid  Dislocation  of  the  Shoulder-joint.  Note  the 
inward  displacement  of  the  humeral  head,  vv^hieh  lies  just 
below  the  coracoid  process. 


PLATE  XIV. 


Fracture  of  Greater  Tuberosity  of  the  Humerus,  with 
Dovi^nward  Displacement  thereof.  The  usual  signs  of  frac- 
ture permitted  a  ready  diagnosis  to  be  made. 


INJURIES  OF   THE  JOINTS  469 

coracoid  process.  The  elbow  cannot  be  brought  in  toward 
the  median  Hne,  nor  can  the  hand  of  the  injured  arm  be 
placed  upon  the  opposite  shoulder.  Active  and  passive 
movements  are  greatly  restricted,  and  a  soft  crepitus  is 
elicited  on  manipulating  the  arm. 

Fracture  of  the  anatomical  neck  of  the  humerus  is  rare 
and  occurs  chiefly  in  elderly  people.  The  usual  signs  of 
fracture  are  present.  Unless  the  fragments  are  impacted 
the  shoulder  is  flattened  and  there  is  a  sharp  deformity  over 
the  anterior  aspect  of  the  joint. 

Fracture  of  the  surgical  neck  of  the  humerus  affords  the 
usual  signs  of  fracture. 

Sejparation  of  the  upper  humeral  epiphysis  occurs  only  in 
young  people,  never  after  the  twentieth  year,  and  usually 
between  the  ninth  and  seventeenth.  The  forward  and 
inward  displacement  of  the  upper  end  of  the  lower  fragment 
which  usually  attends  this  condition  produces  a  character- 
istic angular  deformity,  the  prominence  being  below  the 
glenoid  cavity  and  at  the  inner  side  of  the  arm.  The  age  of 
the  patient,  the  characteristic  deformity,  the  soft  crepitus,  and 
the  fact  that  the  head  does  not  rotate  with  the  shaft  indicate 
the  nature  of  the  injury. 

If  after  injury  to  the  shoulder  the  joint  is  tender,  painful, 
and  swollen,  and  no  positive  evidences  of  fracture  or  disloca- 
tion are  present,  a  sprain  must  be  assumed.  With  hsemar- 
throsis  the  swelling  of  the  joint  is  soft  and  doughy,  with 
synovitis  fluctuating. 

Elbow-joint. — In  the  examination  of  the  elbow-joint  it  is 
important  to  note  the  relation  of  the  epicondyles  and  tip  of 
the  olecranon  process,  the  position  of  the  radial  head,  the 
carrying  angle,  and  the  range  of  motion. 

In  the  normal  joint  the  two  epicondyles  and  the  tip  of  the 
olecranon  process  should  be  on  the  same  horizontal  plane 
when  the  forearm  is  extended;  deviations  therefrom  are  due 
to  fractures  and  dislocations  of  the  articular  ends  of  the 
bones. 

The  head  of  the  radius  should  lie  below  the  external  condyle 
of  the  humerus,  and  should  move  with  its  own  shaft  in 
pronation  and  supination  of  the  hand. 

The  carrying  angle  is  the  lateral  angle  that  the  supinated 


470     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

forearm  makes  with  the  upper  arm.     It  varies  normally 
within  very  wide  limits  and  may  be  entirely  absent. 

As  regards  movement,  it  is  important  to  remember  that  in 
the  extended  position  of  the  forearm  no  lateral  motion  is 
possible. 

Fig.  175 


The  normal  relation  of  the  two  epicondyles  and  the  tip  of  the  olecranon  prouehS. 
In  the  extended  position  of  the  forearm  these  three  points  should  be  on  the  same 
horizontal  plane. 


Measurements  of  the  joint  are  made  between  the  two 
epicondyles  and  from  the  tip  of  the  acromion  process  to  the 
external  epicondyle  of  the  humerus. 

Dislocation  of  both  bones  of  the  forearm  backward,  with 
or  without  fracture  of  the  coronoid  process  of  the  ulna,  is 
characterized  by  a  disturbance  in  the  relation  of  the  three 


INJURIES  OF   THE  JOINTS 


471 


bony  points,  the  olecranon  tip  being  on  a  higher  level  than 
the    epicondyles ;    by   undue     pominence    of    the    olecranon 


Fig.  176 


Supracondyloid  fracture  of  the  humerus.  The  visible  deformity  is  similar  to  that 
in  posterior  dislocation  of  both  bones  of  the  forearm  as  represented  in  Fig.  177. 
(Hoffa.) 

Ftg. 177 


Posterior  dislocation  of  both  bones  of  the  forearm.    (HoflFa.) 


process  behind,  by  displacement  of  the  radial  head,  and  by 
the  condyles  being  jar  in  front  of  the  olecranon  process. 


472     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

The  visible  deformity  occasioned  by  supracondylar  frac- 
tures resembles  that  which  is  produced  by  this  dislocation; 
but  in  these  fractures  the  condyles  and  olecranon  maintain 
their  normal  relation,  the  radial  head  is  in  its  normal  position 
and  the  deformity  when  reduced  readily  returns. 

Subluxation  of  the  radial  head  is  a  frequent  occurrence  in 
young  children.  The  arm  hangs  slightly  away  from  the  side, 
the  elbow-joint  is  slightly  flexed,  and  the  hand  semi-pronated. 
The  extremes  of  flexion,  extension  and  supination  are  painful. 
The  relation  of  the  three  bony  points  is  preserved,  but  the 
radial  head  does  not  lie  below  the  condyle  of  the  humerus. 
Fractures  of  the  radial  head  or  neck  are  differentiated  from 
the  preceding  by  the  normal  position  of  the  radial  head,  the 
presence  of  crepitus,  and  the  lack  of  movement  of  the  head 
with  the  shaft. 

In  backward  dislocation  of  the  ulna  the  forearm  is  fixed  in 
complete  extension,  the  olecranon  process  is  elevated,  and 
the  forearm  forms  an  obtuse  angle  with  the  arm,  the  apex 
being  directed  away  from  the  median  line. 

Fracture  of  the  olecranon  is  characterized  by  disturbed 
relation  of  the  bony  points,  by  crepitus  and  mobility  of  the 
olecranon  process. 

Fracture  of  the  internal  condyle  of  the  humerus  is  char- 
acterized by  crepitus,  abnormal  mobility  of  the  condyle, 
upward  displacement  of  the  internal  epicondyle,  lateral 
mobility  of  the  joint  in  extension,  adduction  being  especially 
free,  and  by  a  diminished  carrying  angle. 

Fracture  of  the  internal  epicondyle  is  quite  common  in 
young  children.  It  is  attended  with  crepitus  and  downward 
and  forward  displacement  of  the  inner  of  the  three  bony 
points. 

Fracture  of  the  external  condyle  is  marked  by  upward  dis- 
placement of  the  outer  of  the  bony  points.  The  radial  head 
maintains  its  normal  relation  to  the  condyle.  There  is,  as  a 
rule,  abnormal  lateral  mobility  in  the  extended  position,  and 
the  transverse  diameter  of  the  elbow-joint  is  increased. 

With  supracondylar  fracture  there  is  a  marked  fulness  in 
front  of  the  joint  and  a  prominence  of  the  point  of  the  elbow 
behind,  just  as  is  the  case  with  backward  dislocation  of  both 
bones  of  the  forearm.     The  bony  points,  however,  maintain 


INJURIES  OF   THE  JOINTS  473 

their  normal  relation.  There  are  crepitus  and  abnormal 
lateral  and  anteroposterior  mobility  above  the  elbow,  and 
the  deformity  readily  recurs  after  reduction. 

T-shaped  fractures  are  recognized  by  the  crepitus  and 
abnormal  mobility  which  are  to  be  elicited  by  rocking  the 
condyles  upon  one  another,  by  the  disturbed  relation  of  the 
bony  points  (one  or  both  condyles  being  displaced),  by 
the  increased  diameter  between  the  condyles,  and  by  abnor- 
mal range  of  abduction  and  adduction. 

Separation  of  the  lower  epiphysis  is  fairly  common  in 
children  under  ten.  The  bony  points  maintain  their  normal 
relation.  The  diagnosis  is  made  from  the  age  of  the  patient, 
the  history  of  an  injury  to  the  elbow,  the  abnormal  mobility 
of  the  lower  end  of  the  humerus,  the  soft  crepitus,  the  in- 
creased width  between  the  condyles,  and  the  abnormal  lateral 
and  anteroposterior  mobility. 

Disturbances  in  the  relation  of  the  three  bony  points  may 
be  classified  as  follows: 

The  midpoint  is  displaced  upward  in  backward  disloca- 
tions of  both  bones  of  the  forearm,  or  of  the  ulna  alone, 
and  in  fractures  of  the  olecranon. 

The  02iter  point  is  displaced  upward  in  fractures  of  the 
external  condyle. 

The  inner  point  is  displaced  upward  in  fractures  of  the 
internal  condyle,  and  downward  and  forward  in  fractures  of 
the  internal  epicondyle. 

In  T-shaped  fractures  both  lateral  points  are  displaced. 

In  all  other  injuries  the  normal  relation  of  the  bony  points 
is  maintained. 

Wrist-joint. — In  the  examination  it  is  important  to  note 
the  contour  and  shape  of  the  joint,  the  relation  of  the  styloid 
processes  to  each  other,  the  measurement  between  the  two 
styloids,  and  the  range  and  direction  of  active  and  passive 
mobility.  In  the  normal  joint  the  tip  of  the  radial  styloid 
is  lower  than  the  tip  of  the  ulnar  styloid,  and  the  base  of  the 
thenar  eminence  is  consequently  lower  than  that  of  the 
hypothenar. 

Fractures  of  the  lower  end  of  the  radius,  which  are  most 
of  them  Colles'  fractures,  are  characterized  by  a  higher 
relative  position  of  the  thenar  eminence,  as  a  rule  by  antero- 


474     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

posterior  and  lateral  deformities  (the  wrist  presenting  the 
well-known  silver-fork  deformity — i.  e.,  a  flattened  promi- 
nence in  front  just  above  the  joint  and  a  corresponding 
depression  behind),  by  elevation  of  the  radial  styloid  process, 
and,  unless  the  fragments  are  impacted,  by  crepitus  and  false 
point  of  motion. 

Fig. 178 


J 


Marked  abduction  (bayonet  deformity)  in  Colles'  fracture.    (Von  Bergmann.) 

With  the  very  uncommon  dislocation  backward  of  the  carpal 
bones  the  styloids  maintain  their  normal  relation,  but  the 
distance  between  these  processes  and  a  fixed  point  on  the 
hand  is  shortened.  The  displaced  carpal  bones  can  be 
readily  felt,  and  the  deformity  when  reduced  does  not  tend 
to  return. 

Fig. 179 


Backward  displacement  (silver-fork  deformity)  in  Colles'  fracture.  (Von  Bergmann.) 

Separation  of  the  lower  radial  epiphysis  may  be  confounded 
with  Colles'  fracture,  but  it  is  distinguished  therefrom  by  the 
soft  character  of  the  crepitus,  the  slighter  deformity  which 
it  occasions,  and  by  its  occurrence  in  young  subjects. 

Sprains  and  contusions,  though  not  as  common  as  radial 
fractures,  are  recognized  by  the  absence  of  all  the  evidences 
of  fracture  or  dislocation. 


PLATE  XV. 


Colles'  Fracture  of  the  Radius  and  its  most  frequent  com- 
plication— viz..  Fracture  of  the  Tip  of  the  Ulna  Styloid,  which 
latter  permits  of  the  bayonet  deformity.     (Fig.  178.) 


INJURIES  OF   THE  JOINTS 


475 


Hip-joint. — In  examining  an  injured  hip  notice  should  be 
taken  of  the  position  of  the  foot — i.  e.,  whether  it  is  inverted 
or  everted.    The  length  of  the  Hmb,  the  relation  of  the  upper 


Fig.  180 


Nelaton's  line  passing  from  the  anterior  superior  spine  along  the  upper  border  ot 
the  greater  trochanter  to  the  lower  margin  of  the  ischial  tuberosity.  If  a  vertical  line 
is  let  fall  from  the  anterior  superior  spine,  and  then  a  horizontal  line  is  drawn  from 
the  upper  border  of  the  great  trochanter  to  meet  it,  Bryant's  iliofemoral  triangle  will 
be  constructed.  The  length  of  the  base  line  of  this  triangle  as  compared  with  the 
healthy  side  is  important  for  the  recognition  of  fractures  and  dislocation  of  the  hip. 


border  of  the  great  trochanter  to  Nelaton's  line — i.  e.,  a  line 
passing  from  the  anterior  superior  iliac  spine  to  the  lower 
margin  of  the  tuberosity  of  the  ischium,  the  length  of  the 
Bryant  base  line,  and  the  distance  of  the  great  trochanter 


476     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

from  the  median  line  of  the  body  should  all  be  carefully 
measured  and  compared  with  the  sound  side.  Any  marked 
difference  in  the  relations  or  measurements  between  the 
injured  and  healthy  side  is  due  to  fracture  or  dislocation/ 


Fig.  181 


Ftg. 182 


Fig.  181.— Iliac  (backward)  dislocation.  Note  position  of  the  foot,  and  the  shorten- 
ing of  the  limt).    (Bigelow.) 

Fig.  182.— Pubic  (anterior)  dislocation.  Note  position  of  the  foot,  and  the  promi- 
nence over  the  pubic  ramus.    (Bigelow.) 

Backivard  dislocations  of  the  femoral  head  are  characterized 
by  inward  rotation  of  the  foot,  adduction,  flexion,  and 
shortening  of  the  limb,  and,  as  a  rule,  by  displacement  of 
the  upper  trochanteric  margin  above  Nelaton's  line. 

In  anterior  pubic  dislocations  the  foot  is  rotated  outward, 


'  SUght  differences  in  the  measurements  of  the  two  sides  are  sometimes  present 
even  when  the  parts  are  perfectly  normal. 


INJURIES  OF   THE  JOIXTS 


477 


the  limb  is  shortened  and  extended  at  the  hip,  and  the  dis- 
located head  forms  a  visible  or  palpable  prominence  over 
the  horizontal  pubic  ramus. 

In  internal  obturator  dislocations  there  is  little  apparent 
shortening  and  no  palpable  dislocated  head,  but  correspond- 
ing to  the  normal  trochanteric  position  is  a  hollow. 


Fig.  183 


Obturator  (internal)  dislocation.    (Bigelow.) 


In  all  dislocations  it  is  to  be  noted  that  the  trochanter 
points  to  the  position  of  the  head;  for  example,  if  the  tro- 
chanter is  in  front  the  head  must  be  behind. 

Fractures  of  the  femoral  neck  are  often  attended  by  the 
same  position  of  the  Hmb  and  foot  as  are  backward  disloca- 
tions of  the  hip,  and  are  to  be  distinguished  from  the  latter 
by  their  greater  frequency  of  occurrence  in  elderly  subjects, 
by  crepitus,  the  absence  of  flattening  in  the  gluteal  region. 


478     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

by  the  inability  to  feel  the  head  of  the  femur  in  an  abnormal 
position,  and  by  the  head  not  moving  with  the  shaft  of  the 
bone. 

Fig.  184 


Fracture  of  the  femoral  ueck  ;  note  position  of  the  foot.     Compare  with  Figs.  181, 182 

and  183. 


Knee-joint. — The  superficial  situation  of  the  knee-joint 
renders  it  easily  accessible  to  palpation.  In  the  examination 
attention  should  be  directed  to  the  relation  of  the  tibial 


INJURIES  OF  THE  JOINTS  479 

tuberosities,  the  femoral  condyles,  the  fibular  head,  and  the 
patella;  to  the  patient's  ability  to  raise  the  extended  leg;  to 
the  range  of  active  motion  in  flexion  and  extension  and  to 
the  presence  of  abnormal  mobility,  whether  in  flexion, 
extension,  ab-,  or  adduction,  or  rotation.  It  is  important  to 
remember  in  connection  with  the  normal  mobility  of  the  joint 
that  extension  is  possible  only  to  a  straight  line,  and  is 
checked  by  the  lateral  and  posterior  ligaments  and  the 
anterior  crucial  ligament,  that  flexion  is  possible  only  to  135 
degrees,  and  is  checked  by  the  forepart  of  the  capsule,  liga- 
mentum  patellae  and  posterior  crucial  ligaments,  that  abduc- 
tion and  adduction  are  not  possible  at  all,  and  that  in  the 
partly  flexed  position  slight  rotation  inward  and  outward  is 
possible,  the  former  being  checked  by  the  anterior  crucial 
ligament,  the  latter  by  the  lateral  ligaments. 

It  is  most  essential  to  remember  these  natural  ranges  of 
active  mobility  and  the  limiting  factors  thereof,  for  rupture 
of  the  restraining  ligaments  permits  of  abnormal  mobility  of 
the  joint  in  that  direction,  in  which  it  is  limited  by  the  torn 
ligament. 

Supracondylar  femoral  fractures  likewise  permit  of  abnor- 
mal mobility  of  the  leg,  but  these  are  readily  recognized  by 
the  usual  evidences  of  fracture — fulness  in  the  popliteal  space, 
and  shortening  of  the  limb. 

Fracture  of  the  patella  and  rupture  of  the  quadriceps  and 
patellar  tendons  result  in  more  or  less  complete  inability  to 
elevate  the  extended  leg.  Palpation  readily  differentiates 
these  conditions,  for  the  line  of  the  patella  fracture  and  the 
furrow  between  the  ruptured  ends  of  the  quadriceps  or 
patella  ligaments  are  easily  palpable. 

Separation  of  the  femoral  epiphysis  is  frequent  in  children, 
and  is  marked  by  a  soft  crepitus,  by  which  characteristics 
it  is  distinguished  from  supracondylar  fractures,  which  it 
otherwise  resembles. 

Dislocation  of  the  knee-joint,  a  rare  occurrence,  is  readily 
recognized  by  palpation.  If  the  swelling  is  not  excessive 
and  the  patella  does  not  lie  upon  and  fill  up  the  protruding 
tibial  head  the  diagnosis  can  be  made  by  inspection. 

Rupture  of  the  lateral  ligaments  permits  of  abnormal 
abduction,  adduction,  and  rotation,  depending  upon  whether 


480      INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

the  internal  or  external  ligament  has  been  torn.  Rupture  of 
the  crucial  ligaments  permits  of  hyperextension  and  abnormal 
rotation. 

Ankle-joint.— In  the  examination  note  should  be  taken  of 
the  integrity  of  the  malleoli  and  of  the  fibula  above  the  tibio- 
fibular joint,  of  the  relation  of  the  malleoli  to  the  astragalus, 
and  of  the  function  and  position  of  the  foot. 

Fractures  of  the  fibula  anywhere  between  the  tip  of  the 
malleolus  and  three  inches  above  it  afford  the  usual  evidences 
of  broken  bones.  Should  there  be  a  coincident  rupture  of 
the  internal  lateral  and  inferior  tibiofibular  ligaments,  or  a 
fracture  of  the  internal  malleolus,  an  abnormal  mobility  of 
the  foot,  and  in  some  cases  a  backward  displacement  of  the 
foot,  results.  In  the  latter  instance  the  foot  is  shorter  (as 
measured  from  the  front  of  the  ankle  to  the  cleft  between 
the  first  and  second  toes)  and  everted. 

Simple  dislocations  of  the  ankle  are  rare,  but  are  readily 
recognized,  the  tibia  being  either  in  front  of  or  behind  the 
astragalus.  In  the  former  instance  the  foot  is  in  plantar 
flexion,  the  heel  is  prominent,  the  Achilles  tendon  concave 
posteriorly,  and  the  anterior  aspect  of  the  foot  is  shortened. 
In  the  latter  the  foot  is  in  dorsal  flexion,  the  heel  disappears, 
and  the  anterior  aspect  of  the  foot  is  lengthened. 


CHAPTER   L. 
ACUTE  INFLAMMATIONS  OF  JOINTS. 

The  same  exciting  causes  of  joint  inflammation  at  one 
time  attack  the  synovial  membrane  alone,  with  resulting 
acute  or  chronic  synovitis,  and  at  another  time  all  the 
structures  of  the  joint  with  resulting  acute  or  chronic  pan- 
arthritis. 

The  acute  inflammations  are  distinguished  from  the  chronic 
ones  by  the  presence  of  more  or  less  severe  constitutional 
disturbances — i.  e.,  high  fever,  rapid  pulse,  and  increased 
leukocyte  count.  It  is  to  be  remembered  that  an  acute 
inflammatory  condition  may  subside  into  a  chronic  one. 
The  participation  of  all  the  joint  structures  in  an  inflam- 
matory process  readily  distinguishes  a  panarthritis  from  a 
synovitis. 

Acute  Synovitis, — The  acute  forms  of  synovitis  are  due 
to  traumatism,  rheumatism,  gout,  pyajmia,  gonorrhoea,  and 
the  acute  infectious  diseases,  and  are  characterized  by  a 
moderately  severe  grade  of  constitutional  symptoms,  and  by 
a  distention  of  the  capsule  with  serum,  or  seropus,  or  pus. 
The  severity  of  the  constitutional  symptoms  depends  entirely 
on  the  grade  and  severity  of  the  synovial  inflammation. 
The  joint  is  painful  and  tender;  if  it  is  a  superficial  one  the 
overlying  skin  is  hot,  and  the  limb  is  usually  held  in  slight 
flexion.  The  muscles  may  undergo  atrophy.  The  evidences 
of  capsular  distention  have  been  described  on  page  457. 

The  nature  and  cause  of  the  synovitis  must  be  ascertained 
from  the  history  and  from  evidences  of  disease  in  other 
organs. 

Thus  in  rheumatism  there  are  profuse  acid  sweats,  highly 
colored  urine,  and  multiple  joint  involvement.  In  gonorrhoea 
the  joint  symptoms  generally  commence  after  the  third  week 
of  the  urethritis,  though  they  occasionally  develop  during  the 

31 


482     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

chronic  stage  of  the  disease;  one  or  many  joints  may  be 
involved.  In  pyoemia  there  is  a  primary  focus  for  the  systemic 
infection,  though  cryptogenetic  forms  of  infection  do  occur; 
the  constitutional  symptoms  are  more  severe  and  the  exudate 
is  purulent.  With  traumatic  synovitis  the  history  of  an  injury 
is  always  present. 

The  chronic  forms  of  synovitis  are  either  the  remains  of 
an  acute  inflammation  or  they  are  chronic  from  the  outset,  in 
which  case  they  are  for  the  most  part  due  to  typhoid,  or 
syphilis,  or  tuberculosis.  The  constitutional  manifestations 
are  very  mild  or  altogether  absent.  The  capsule  becomes 
distended  with  serous  or  seropurulent  or  purulent  fluid,  the 
synovial  membrane  becomes  thickened,  its  fringes  at  times 
considerably  hypertrophied,  and  motion  of  the  joint  often 
elicits  crepitation.  Usually  there  is  no  pain  nor  is  there 
much  restriction  of  motion;  the  chief  complaint  is  that  the 
limb  becomes  easily  tired  and  does  not  feel  as  strong  as 
before.  In  some  instances  the  exudate  is  very  slight,  but 
the  thickening  of  the  synovial  membrane  and  its  fringes  is 
very  much  in  evidence,  causing  pain  and  marked  crepitation. 
As  in  the  acute  forms  of  the  disease,  the  diagnosis  of  the 
exciting  cause  of  the  chronic  synovitis  must  be  determined 
from  the  anamnesis,  from  the  physical  examination  and  by 
a  process  of  exclusion.  The  tuberculous  forms  of  the  disease 
are  characterized  by  their  persistence  in  spite  of  the  usual 
methods  of  treatment,  by  the  greater  amount  of  synovial 
thickening,  the  greater  frequency  of  crepitation,  and  a 
yellowish,  flocculent  exudate. 

Acute  Arthritides. — The  acute  arthritides  are  nearly 
always  due  to  infection  of  the  joint  with  bacteria,  the  infec- 
tion taking  place  through  open  wounds  or  from  perforation 
of  a  neighboring  suppurating  focus  into  the  joint,  or  by  the 
medium  of  the  blood  stream.  They  are  thus  for  the  most 
part  secondary  lesions  and  accordingly  are  found  to  develop 
after  penetrating  wounds  of  the  joints,  with  acute  infectious 
osteomyelitis  or  epiphysitis,  with  pyaemia,  typhoid  fever, 
pneumonia,  the  acute  infectious  diseases,  and  gonorrhoea. 

The  constitutional  symptoms  attending  these  acute  arthri- 
tides are  usually  severe;  the  temperature  is  high,  the  pulse 
rapid,  the  leukocyte  count  high,  and  the  patients  look  and 


ACUTE  INFLAMMATIONS  OF  JOINTS  483 

feel  very  sick.  The  joint  is  painful  and  swollen,  the  skin 
red  and  hot,  the  periarticular  structures  infiltrated  and 
thickened,  the  capsule  distended  with  seropus  or  pus,  the 
articular  ends  of  the  bones  and  the  ligaments  tender,  active 
and  passive  motion  exceedingly  painful  and  the  limb  is  held 
in  a  more  or  less  flexed  position. 

The  cause  of  the  disease  is  determined  from  the  clinical 
history,  the  presence  of  clinical  evidences  of  disease  in  other 
organs — e.  g.,  acute  osteomyelitis,  pneumonia,  acute  infec- 
tious diseases,  gonorrhoea,  etc.  It  is  to  be  especially  noted 
that  a  joint  inflammation  may  be  the  first  objective  sign 
of  an  acute  infectious  osteomyelitis,  and  consequently  in 
young  children  in  whom  no  other  cause  for  the  acute  arthritis 
can  be  discovered  such  acute  infection  of  the  bone-marrow 
or  epiphysis  should  be  suspected  and  looked  for. 

In  some  of  the  arthritides  following  acute  osteomyelitis 
the  course  is  subacute,  the  constitutional  symptoms  being 
considerably  less  severe,  the  joint  inflammation  less  intense, 
and  the  exudate  within  the  joint  of  a  ropy,  viscid  character. 
These  cases  belong  to  the  class  described  by  Volkmann  as 
"catarrhal  synovitis." 

Joint  exudates  and  periarticular  effusions  of  a  serous, 
seropurulent,  or  purulent  character  sometimes  accompany 
severe  forms  of  osteomyelitis  and  periarthritis,  even  though 
no  real  joint  inflammation  exists.  Such  collateral  exudates 
are  similar  to  the  exudates  which  form  in  the  soft  parts 
around  a  virulent  focus  of  infection.  If  they  are  purulent 
in  character  it  may  be  very  difficult  to  differentiate  them 
from  those  which  are  due  to  a  true  arthritis.  When  the 
joint  is  opened  the  synovial  membrane  is  seen  to  be  bright 
and  shiny  and  not  coated  with  fibrin,  and  spreads  made  from 
the  exudate  show  no  bacteria.  All  such  exudates  disappear 
spontaneously  when  the  primary  focus  of  disease  is  incised 
and  drained. 

An  arthritis  and  a  collateral  exudate  into  a  joint  secondary 
to  acute  infectious  osteomyelitis  are  sometimes  mistaken  for 
rheumatism,  and  especially  is  this  likely  to  happen  when  the 
bone  disease  gives  no  physical  evidences  of  its  presence.  In 
favor  of  osteomyelitis  are  the  presence  of  pain  and  tenderness 
at  the  articular  ends  of  the  bones,  a  periarticular  exudate, 


484     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

and  the  frequency  of  this  disease  in  children  in  whom  rheu- 
matism is  comparatively  infrequent.  The  tendency  for  rheu- 
matism to  affect  a  number  of  joints  also  distinguishes  this 
malady  from  the  acute  arthritis  secondary  to  bone  disease. 
Gouty  and  Rheumatic  Arthritides. — Gouty  and  rheu- 
matic arthritides  are  special  forms  of  acute  joint  inflam- 
mation and  do  not  end  in  suppuration.  The  gouty  attacks 
frequently  commence  in  the  middle  of  the  night,  the  meta- 
tarsophalangeal joint  of  the  big  toe  and  the  metacarpo- 
phalangeal joint  of  the  thumb  being  the  favorite  sites  of  the 
disease.  The  joints  become  swollen  and  acutely  painful; 
the  overlying  skin  is  red,  shiny,  and  oedematous.  The  symp- 
toms pass  off  in  a  few  days,  but  the  attacks  recur  from  time 
to  time.  Each  one  leaves  a  slight  deposit  of  biurate  of  soda 
in  the  articular  cartilage,  ligaments,  and  ends  of  the  bones, 
which  finally  forms  well-marked  swellings  (tophi)  around 
the  joint.  Similar  deposits  are  found  in  the  external  ear  and 
other  cartilaginous  structures. 


CHAPTER   LI. 

CHRONIC  DISEASES  OF  THE  JOINTS. 

TUBERCULOSIS  OF  THE  JOINTS. 

The  cure  of  tuberculous  arthritis,  whether  by  the  bloody 
or  bloodless  methods  of  treatment,  will  be  the  more  probable 
the  earlier  the  diagnosis  is  made.  With  the  truth  of  this 
statement  acknowledged  by  all,  it  becomes  the  duty  of  every 
practitioner  to  carefully  study  and  examine  his  cases  of  joint 
disease  so  as  to  be  able  at  the  earliest  possible  opportunity 
to  institute  such  curative  methods  as  are  most  applicable. 
It  must  not  be  imagined,  however,  that  such  early  diagnosis 
is  easy,  for  in  its  initial  stages  tuberculous  arthritis  is  very 
often  attended  by  few  symptoms,  and  these  are  elicited  only 
after  careful  examination. 

The  majority  of  the  patients  with  this  ailment  are  children 
who  have  a  tendency  to  hide  their  malady  rather  than  expose 
it,  and  only  by  careful  observation  of  their  previous  and 
present  actions  and  habits  can  a  clue  be  obtained  that  some- 
thing is  wrong.  Such  careful  observation,  combined  with 
repeated,  painstaking  physical  and  a:r-ray  examination,  will, 
in  most  cases,  enable  us  to  make  an  early  diagnosis  of 
tuberculous  joint  disease. 

If  the  patient  is  a  child  the  mother  will,  as  a  rule,  attribute 
its  slight  limp  or  the  fact  that  it  easily  tires  at  play,  or 
refuses  to  use  its  arm  as  before,  to  an  injury;  a  little  cross- 
questioning,  however,  will  soon  reveal  the  fact  that  the 
supposed  traumatism  was  very  slight  and  was  only  thought 
of  when  the  child  commenced  to  complain.  The  patient, 
although  previously  a  sound  sleeper,  is  now  said  to  wake  up 
at  night  with  a  cry  and  then  fall  asleep  again.  Pain  mav  be 
complained  of  in  the  affected  joint  or  it  may  be  referred  to 
another  joint — e.  g.,  to  the  knee  in  hip-joint  disease. 


486     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

If  the  individual  is  examined  at  this  stage  there  may  be 
no  objective  signs.  This  should  not  lead  the  examiner  to 
dismiss  the  case  as  one  of  minor  or  insignificant  importance, 
but  should  prompt  him  the  more  to  make  repeated  exami- 
nations. Sooner  or  later  pathognomonic  signs  of  joint  disease 
are  manifested.  Such  evidences  are,  firstly,  a  restriction  in 
the  free  passive  motion  of  the  joint  in  some  or  all  of  the 
directions  in  which  it  normally  moves,  such  restricted  move- 
ment being  associated  with  reflex  muscular  spasm;  and, 
secondly,  the  abnormal  position  in  which  the  joint  is  held 
when  at  rest.  The  a:-ray  may  show  changes  in  the  ossification 
nucleus  of  the  epiphysis  and  in  the  osteocartilaginous  junc- 
tions of  the  articular  ends,  for  which  see  pp.  463-465. 

These  early  objective  evidences  of  disease  are,  as  stated 
above,  pathognomonic,  and  their  presence  should  be  repeat- 
edly sought  for  in  patients  presenting  the  subjective  symp- 
toms detailed  above. 

As  the  disease  progresses  the  objective  manifestations, 
become  more  numerous  and  evident.  The  joint  if  a  super- 
ficial one  becomes  swollen,  its  contour  obliterated,  its  shape 
fusiform,  the  periarticular  structures  and  capsule  thickened 
and  infiltrated,  and  the  articular  ends  of  the  bone  enlarged. 
The  skin  becomes  stretched,  pale  and  waxy,  the  cutaneous 
veins  distended  and  enlarged,  motion  more  restricted,  and 
reflex  muscular  spasm  more  marked;  the  limb  is  held  in  a 
vicious  position  and  the  pain  is  more  intense.  The  general 
health  also  commences  to  suffer;  the  pain  interferes  with 
sleep,  and  the  progressing  tuberculous  infection  causes 
anaemia,  loss  of  appetite,  and  loss  of  weight. 

If  the  malady  continues  to  advance  the  tuberculous  tissue 
in  the  bone  and  within  the  joint  undergoes  caseation,  breaks 
through  the  periosteum  and  capsule  into  the  soft  parts,  and 
gives  rise  to  cold  abscesses  which  perforate  through  the  skin 
in  the  neighborhood  of  the  joint,  or  burrow  along  the  muscular 
planes  and  perforate  through  the  skin  at  a  distance  from  the 
original  site  of  the  disease.  The  destruction  of  the  joint 
structures  leads  to  dislocation.  If  now  a  mixed  pyogenic 
infection  through  the  fistulous  opening  occurs  profuse  sup- 
puration results.  The  general  health  suffers  materially;  the 
constant  discharge  and  fever  sap  the  strength,  the  pain  inter- 


CHRONIC  DISEASES  OF   THE  JOINTS  487 

feres  with  sleep,  and  the  appetite,  digestion,  and  assimilation 
are  bad. 

Differential  Diagnosis. — The  initial  symptoms  of  tuber- 
culous arthritis  bear  some  similarity  to  the  pains  that  attend 
growth  and  to  the  manifestations  of  hysterical  joints. 
Growing  pains,  by  some  attributed  to  very  mild  forms  of 
osteomyelitis,  are  usually  in  the  shafts  of  the  long  bones, 
more  rarely  in  the  joints.  They  disappear  with  rest  in  bed, 
and  are  not  associated  with  restricted  joint  movement  or 
reflex  muscular  spasm. 

Hysterical  and  neuralgic  joint  pains  are  characterized  by 
their  inconstancy,  now  better,  now  worse,  now  here,  now 
there,  and  by  their  association  with  other  hysterical  symp- 
toms. Though  the  joints  may  be  held  in  vicious  positions 
that  resemble  those  which  result  from  real  disease,  even 
muscular  atrophy  from  disuse  being  associated  with  such 
malpositions,  the  physical  examination  reveals  no  abnor- 
malities and  in  narcosis  there  is  no  restriction  of  joint  move- 
ment and  no  reflex  muscular  spasm.  The  physical  sufferings 
are  entirely  disproportionate  to  the  actual  findings,  and  with 
massage  and  general  hygienic  and  electric  treatment  the 
neuralgic  and  hysterical  pains  as  a  rule  subside  entirely. 

In  the  stage  of  effusion  with  swelling  of  the  joint  and 
periarthritis,  tuberculous  arthritis  bears  some  resemblance 
to  monarticular  rheumatism,  to  acute  and  chronic  synovitis, 
to  gonorrhoeal  and  syphilitic  arthritis,  to  the  arthritis  which 
is  secondary  to  acute  osteomyelitis  and  to  malignant  disease 
of  the  articular  ends  of  the  bones. 

Monarticular  rheumatism  is  distinguished  by  its  tendency 
to  repeated  recurrence,  and  by  the  increased  severity  of  the 
pain  in  wet  weather.  Joint  crepitus,  greater  pain,  and 
stiffness  characterize  the  rheumatic  affections,  which  further- 
more are  favorably  influenced  by  antirheumatic  remedies. 

Chronic  synovitis  is  not  attended  with  as  much  synovial 
thickening  nor  with  the  periarthritis. 

Acute  synovitis  is  always  secondary  to  a  constitutional 
disease — e.  g.,  rheumatism,  gout,  infectious  diseases,  septi- 
caemia, osteomyelitis,  etc.  It  is  of  sudden  onset  in  a  previously 
healthy  joint,  whereas  the  acute  form  of  tuberculous  synovitis, 
which  is  due  to  the  perforation  of  a  tuberculous  bone  focus 


488     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

into  the  joint  cavity,  is  preceded  by  symptoms  which  are  very 
suggestive  of  bony  tuberculosis — e.  g.,  pain,  hmping,  easy 
exhaustion,  etc. 

The  acute  initial  stages  of  gonorrhoeal  arthritis  are  readily 
distinguished  from  the  chronic  manifestations  of  tuberculous 
joints.  The  ankylosis  to  which  it  gives  rise  in  the  later  stages 
differs  from  the  ankylosis  in  tuberculous  disease  by  its  greater 
firmness.  Such  joint  lesions  usually  follow  directly  upon  an 
acute  gonorrhoea  or  occur  during  its  chronic  stage. 

Syphilitic  arthritis  is  likewise  distinguished  by  the  intensity 
of  the  pain  which  attends  it,  and  the  firmness  of  the  ankylosis 
to  which  it  gives  rise.  The  subjective  symptoms  are  relieved 
by  antispecific  treatment. 

The  arthritides  which  follow  the  acute  infectious  diseases 
result  in  ankylosis,  which  may  be  falsely  interpreted  as  due 
to  tuberculosis;  the  anamnesis  affords  the  basis  for  the 
differentiation. 

The  severe  initial  period  of  acute  osteomyelitis  and 
epiphysitis  readily  differentiates  the  joint  affections  to  which 
they  give  rise  from  those  which  are  due  to  tuberculosis.  If 
the  acute  process  subsides,  leaving  a  thickened  joint  with 
periarthritis,  and  especially  if  sinuses  form  and  lead  down 
to  bare  bone,  tuberculosis  may  be  suspected;  the  anamnesis 
in  such  cases  is  more  valuable  for  differentiation  than  are 
the  physical  findings. 

The  pain  and  enlargement  of  joints  due  to  arthritis 
deformans  may  give  one  the  impression  of  tuberculosis.  The 
intensity  of  the  pain,  the  rigidity,  the  cartilaginous  and  fibrous 
thickening,  the  multiple  character  of  the  lesion,  the  more 
chronic  course  and  the  non-suppurative  character  of  arthritis 
deformans  will  serve  to  distinguish  these  joint  affections  from 
those  due  to  tuberculosis. 

Sarcoma  and  carcinoma  of  the  articular  ends  of  the  bones 
may  bear  some  resemblance  to  tuberculosis.  If  there  is  a 
primary  carcinomatous  neoplasm  in  some  other  organ  the 
diagnosis  of  the  secondary  bone  deposit  is  readily  made.  In 
primary  sarcoma  of  the  bones  it  is  well  to  remember  that 
these  growths  occur  later  in  life,  whereas  tuberculosis  is  more 
frequent  in  childhood.  Primary  periosteal  neoplasms  grow 
more  rapidly  and  to  larger  dimensions  than  do  tuberculous 


CHRONIC  DISEASES  OF   THE  JOINTS  489 

lesions ;  they  infiltrate  the  surrounding  tissues  and  more  often 
give  rise  to  secondary  deposits  in  the  glands  and  internal 
organs.  Primary  medullary  sarcomata  expand  and  erode 
the  bone  and  often  first  signify  their  presence  by  spontaneous 
fracture. 

Injuries  to  the  joints  resulting  in  fracture  of  the  articular 
ends  of  the  bones,  or  epiphyseal  separation,  may  simulate 
tuberculous  disease  thereof.  A  little  cross-questioning  will 
elicit  the  history  of  a  severe  injury  in  the  former  case,  which, 
with  an  entire  absence  of  all  other  evidences  pointing  to 
tuberculous  disease,  should  readily  enable  us  to  make  the 
diagnosis. 

Enlarged  and  inflamed  hursos  or  hernial  protrusions  of  the 
synovial  membrane  through  weak  spots  in  the  fibrous  capsule 
may  cause  swelling  of  the  joint  and  vicious  positions  thereof 
that  harmonize  somewhat  with  those  due  to  joint  tuber- 
culosis. These  bursse  sometimes  communicate  with  the 
joint,  and  when  inflamed  the  process  may  extend  from  them 
into  the  joint  cavity,  or,  vice  versa,  the  disease  may  extend 
into  the  bursse  from  the  joint  cavity.  If  the  bursse  alone  are 
diseased,  the  position  of  the  swelling  to  which  they  give  rise 
at  once  distinguishes  them  from  joint  disease  'per  se  (see 
p.  457);  but  if  the  joint  is  involved  coincidently  with  its 
surrounding  bursse,  and  if  there  is  much  periarthritis,  the 
enlarged  bursse  will  be  recognized  with  considerable  difficulty. 

CLINICAL  AND   DIAGNOSTIC   FEATURES  OF  TUBERCU- 
LOUS DISEASE  OF  THE  SPECIAL  JOINTS. 

Shoulder-joint. — ^This  is  rarely  affected  in  children  and 
but  seldom  in  adults. 

Chnically  it  manifests  itself  either  as  a  dry  caries  of  the 
bones,  the  humerus  being  primarily  involved,  or  as  a  fungus 
degeneration  of  the  joint  structures.  The  former  type  of  the 
disease  is  characterized  by  intense  pain,  which  in  the  absence 
of  definite  physical  abnormalities  may  lead  one  to  the 
erroneous  diagnosis  of  joint  neurosis  or  joint  rheumatism. 
The  fungus  forms  of  the  disease  may  simulate  and  must  be 
differentiated  from  neoplasms  of  the  articular  ends  of  the 
bones. 


490     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

Elbow-joint. — Elbow-joint  tuberculosis  is  most  commonly 
met  with  in  young  adults. 

Wrist-joint.— Wrist-joint  tuberculosis  is  most  frequent  in 
young  adult  and  middle  life.    The  disease  usually  commences 

Fig.  185 


Tuberculous  tenosynovitis  around  wrist-joint.    Note  the  figure-of-8  shape. 

with  disturbed  function  of  the  joint  or  a  slowly  increasing 
exudation  into  the  joint  cavity,  to  which  atrophy  of  the  arm 
muscles  succeeds. 

Tuberculous  tenosynovitis  may  be  mistaken  on  superficial 
examination  for  wrist-joint  disease,  an  error  that  should  be 


Fig. 186 

3 

^^l^^l 

^^^ 

^ 

Tuberculous  teuosynoviiis  around  the  wrist,  seen  in  profile.  Note  that  the 
swelling  Is  not  spindle-shaped  nor  limited  to  the  wrist-joint,  as  is  the  case  of 
tuberculosis  of  the  wrist-joint. 

easily  avoided  with  careful  examination  and  a  little  reflection. 
For  the  swelling  which  is  due  to  a  tenosynovitis  is  strictly 
limited  to  the  course  of  the  affected  tendon  sheaths,  and 
usually   has    a   figure-of-8   shape,   the    constricted    portion 


PLATE  XVI. 


Early  Stage  of  the  Disease  of  the  Left  Hip-joint  (to  the 
right  in  the  picture)  of  the  Synovial  Type,  showing  Irregu- 
larity in  the  Shape  of  the  Acetabulum.     (Whitman.) 


CHRONIC  DISEASES  OF   THE  JOINTS  491 

corresponding  to  the  annular  ligament,  beneath  which  the 
tendons  pass.  The  swelling  in  wrist-joint  disease,  on  the 
other  hand,  is  limited  to  the  wrist-joint  and  has  a  spindle 
shape. 

The  frequent  occurrence  of  rice  bodies  in  tendon-sheath 
tuberculosis,  and  the  fact  that  motion  in  this  malady  is 
restricted  only  in  those  directions  in  which  the  affected 
tendons  are  put  on  the  stretch,  and  that  such  limitation  of 
motion  is  not  accompanied  by  reflex  muscular  spasm  further 
distinguish  this  disease  from  wrist-joint  tuberculosis. 

Hip-joint.— Hip-joint  tuberculosis  is  especially  frequent  in 
children.  Its  clinical  course  varies  but  little  from  that  which 
has  been  pictured  above  as  characteristic  of  tuberculous  joint 
disease.  During  the  early  stages  of  the  malady  the  affected 
limb  appears  to  be  lengthened,  and  is  usually  held  in  a 
position  of  flexion,  abduction,  and  eversion,  more  rarely  in 
adduction,  flexion,  and  inward  rotation.  The  flexion  and 
abduction  are,  however,  not  always  in  evidence;  they  may  be 
and  usually  are  masked  by  a  forward  curvature  of  the  spine 
(lordosis)  and  by  tilting  of  the  pelvis,  the  latter  being  the 
cause  of  the  apparent  lengthening.  By  placing  the  patient 
flat  upon  his  back  with  his  spine  absolutely  horizontal  the 
deception  is  unmasked,  for  the  diseased  limb  at  once  flexes 
at  the  hip-joint.  Similarly,  if  while  the  patient  is  flat  and 
horizontal  a  straight  rod  is  laid  across  the  anterior  superior 
iliac  spines,  the  tilting  of  the  pelvis  is  at  once  demonstrated, 
for  the  rod  does  not  lie  at  right  angles  with  the  median  line 
of  the  body  as  it  should;  it  crosses  it  obliquely  and  its  deflec- 
tion downward  on  the  diseased  side  indicates  the  angle  of 
abduction. 

In  the  latei'  stages  of  the  disease  the  position  in  which  the 
limb  is  held  changes  to  adduction,  flexion,  and  inversion; 
the  pelvis  is  tilted  upward  on  the  diseased  side,  causing 
apparent  shortening  of  the  limb.  A  lateral  spinal  curvatufe 
with  the  convexity  to  the  sound  side  in  the  lumbar  region 
follows  upon  the  abnormal  position  of  the  limb. 

When  cold  abscesses  form  they  point  most  frequently  in 
front  of  and  internal  to  the  great  trochanter;  sometimes  they 
point  in  the  gluteal  region  or  below  Poupart's  ligament  to 
the  inner  side  of  the  femoral  vessels.    Sometimes  the  tuber- 


492     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 


culous  process  involves  the  psoas  bursa,  and  the  caseation  of 
the  latter  gives  rise  to  an  abscess  in  the  lower  part  of  Scarpa's 


Fig. 187 


Fig. 188 


f 


Fig.  187. — Coxitis  in  the  stage  of  flexion,  abduction,  and  outward  rotation.  (Von 
Bergmann.) 

Pig.  188.— Apparent  lengthening.  When  the  distorted  Umb  is  brought  to  the 
median  line  the  pelvis  is  so  tilted  that  the  abducted  leg  seems  longer.    (Whitman.) 

triangle,  or  in  the  psoas  muscle.      If  the  acetabulum  is  per- 
forated by  the  tuberculous  process  a  pelvic  abscess  develops. 


PLATE  XVIL 


Advanced  Disease,  showing  Wandering  of  Acetabulum 
and  the  Obliquity  of  the  Pelvis  due  to  Adduction.  Actual 
shortening  one  inch,  apparent  shortening  three  inches. 
(Whitman.) 


I 


CHRONIC  DISEASES  OF  THE  JOINTS 


493 


In  the  final  stages  of  the  disease  the  head  of  the  femur, 
the  posterior  margin  of  the  acetabular  cavity,  and  the  joint 
Hgaments  have  been  eroded  and  destroyed,  permitting  a  back- 
ward dislocation  of  the  femoral  head  and  causing  a  real 


Fig.  189 


Flexion  of  the  hip,  lonlosis  of  tlie  hivnbar  vertebra'.     (Von  Bergmann.) 


shortening,  the  limb   being  adducted,  flexed,   and  rotated 
inward. 

Some  difficulty  may  be  experienced  in  differentiating 
tuberculous  spondylitis  from  tuberculous  coxitis,  for  the  cold 
abscesses  which  result  from  the  former  may  point  and  open 


Fig. 190 


The  degree  of  flexion  is  shown  when  the  lumbar  spine  is  held  in  contact  with  the 
table  by  flexing  the  other  thigh.    (Whitman.) 

in  the  same  regions  as  those  resulting  from  coxitis,  and  the 
reflex  spasm  of  the  ileopsoas  muscle  which  frequently  accom- 
panies vertebral  disease  occasions  the  same  vicious  position 
of  the  lower  extremity — viz.,  flexion,  abduction,  and  outward 


494     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

rotation.  Examination,  however,  will  readily  clear  up  the 
doubt  in  the  diagnosis,  for  with  spondylitis  there  is  tenderness 
over  the  vertebral  spines  or  transverse  processes,  and  usually 

Fig.  191 


Showing  how  to  determine  degree  of  abduction.    (Whitman.) 

some  deformity  (kyphosis,  or  lordosis,  or  lateral  curvature) 
with  rigidity  of  the  spine;  the  movements  of  the  hip-joint, 
on  the  other  hand,  are  free,  and  there  is  no  reflex  muscular 


CHRONIC  DISEASES  OF   THE  JOINTS 


495 


spasm  excited  during  its  passive  motion.    The  x-ray  will  give 
further  evidence  for  differential  diagnosis. 

The  pathological  dislocation  of  the  femoral  head  attending 
the  advanced  stages  of  hip-joint  disease  may  possibly  cause 


Fig. 192 


Fig. 193 


Coxitis  in  the  stage  of  flexion,  adduction, 
and  inward  rotation.    (Von  Bergmann.) 


Coxa  vara.    (Kocher.) 


this  affection  to  be  confounded  with  coxa  vara,  congenital 
hip-joint  dislocation,  and  fracture  of  the  neck  of  the  femur. 
The  cc-ray  will,  as  a  rule,  afford  sufficient  data  for  the  recog- 


496     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

nition  of  the  last-named  diseases,  but  in  addition  there  is  with 
fractures  and  dislocations  the  history  of  a  severe  traumatism. 
In  congenital  dislocation  there  is  no  pain  on  motion  of  the 

Fig. 194 


Unilateral  congenital  dislocation  of  the  hip.    (Von  Bergmann.; 


hip  nor  reflex  muscular  spasm;  the  affection  dates  from  birth 
in  contradistinction  to  tuberculosis,  in  which  the  disease 
develops  after  the  child  has  been  able  to  walk  naturally  and 


CHRONIC  DISEASES  OF   THE  JOINTS 


497 


normally,  and  finally  the  gait  is  waddling  and  the  head  of  the 
bone  can  be  felt  to  slide  upward  on  the  dorsum  of  the  ilium 
as  the  patient  brings  the  weight  of  the  body  upon  the  leg. 

With  coxa  vara  there  is  likewise  no  pain  nor  reflex  muscular 
spasm  elicited  on  moving  the  joint,  though  the  limping, 


Fig. 195 


Bilateral  congenital  dislocation  of  the  hip.    (Von  Bergmann.) 


shortening  and  vicious  position  of  the  limb  in  adduction, 
extension,  and  outward  rotation  may  strongly  suggest  hip-joint 
tuberculosis. 

Knee-joint. — Knee-joint  tuberculosis  is  common.  .Though 
it  usually  commences  in  the  femur  or  tibia,  the  earliest 

32 


498     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

manifestations  are  from  the  diseased  synovial  membrane. 
As  a  rule  there  is  first  of  all  an  effusion  into  the  joint,  with 
thickening  of  the  synovial  membrane,  thus  resembling  in 
every  respect  a  chronic  hydrops.  The  differentiation  is  to  be 
made  by  finding  evidences  of  tuberculosis  in  other  organs, 
by  the  absence  of  any  etiological  factor  to  account  for  the 
hydrops — e.  g.,  trauma,  rheumatism,  or  gonorrhoea — by  the 
tendency  of  the  effusion  to  persist  and  to  recur  in  spite  of 
the  usual  methods  of  treatment,  by  the  greater  thickening 
of  the  synovial  membrane  (especially  to  be  appreciated  at 
the  sides  of  the  patella  and  in  the  space  between  the  articu- 
lating bones),  by  the  crepitation  which  is  to  be  elicited  on 
moving  the  fluid  around  within  the  joint,  and  by  the  yellow- 
ish, flocculent  character  of  this  fluid.  In  these  early  stages 
the  function  of  the  joint  is  but  little  disturbed,  only  the  ex- 
tremes of  flexion  and  extension  being  limited. 

This  effusion  may  after  a  time  gradually  become  less,  and 
be  replaced  by  a  fungous  thickening  of  the  synovial  mem- 
brane. In  some  cases  the  fungous  degeneration  of  the  joint 
structures,  is  the  first  evidence  of  the  disease.  As  a  result 
of  such  fungous  degeneration  the  joint  gradually  becomes 
enlarged  and  either  assumes  a  spindle  shape,  to  which  the 
atrophy  of  the  quadriceps  contributes,  or  when  only  one 
part  of  the  synovial  membrane  is  thickened  the  enlarge- 
ment resembles  that  due  to  a  sarcoma.  The  consistency 
of  the  joint  is  firm,  and  no  fluctuation  or  dancing  patella 
is  present. 

Ankle-joint. — Ankle-joint  tuberculosis  is  marked  in  its 
early  stages  by  pain  and  swelling,  the  latter  being  especially 
noticeable  at  the  sides  of  the  extensor  tendons,  in  the  region 
of  the  malleoli,  and  on  the  posterior  aspect  of  the  joint.  The 
foot  is  held  in  plantar  flexion,  and  if  the  astragalocalcanean 
joint  is  involved  the  foot  is  likely  to  be  fixed  in  adduction 
and  supination. 

The  pain  and  swelling  of  the  ankle  due  to  flat-foot  are 
readily  distinguished  from  that  due  to  tuberculous  disease  of 
the  ankle  by  the  presence  of  the  sunken  arch,  the  associated 
pains  in  the  calf,  and  the  absence  of  limitation  of  movement 
in  the  ankle  with  reflex  muscular  spasm. 

Tuberculous  tenosynovitis    is  distinguished  from    tuber- 


PLATE  XVIII. 


Tuberculosis  of  the   Knee-joint,   advanced,  stage,   engrafted 
upon  an  old  gonorrhoeal  inflammation. 

Note  the  fungous  masses  in  the  joint  eavity,  the  enlargement  of  the 
tibial  head  and  patella,  and  the  irregularity  of  the  cartilages  covering  the 
articulating  surfaces. 


CHRONIC  DISEASES  OF   THE  JOINTS  499 

culous  arthritis  of  the  ankle  by  the  same  characteristics  as 
distinguish  tenosynovitis  in  the  hand  from  wrist-joint  disease. 
(See  p.  490.) 

Astragalocalcanean  Joint. — Tuberculosis  of  the  astragalo- 
calcanean  joint  is  characterized  by  a  lower  site  of  the  swelling 
than  in  ankle-joint  disease  and  by  the  absence  of  swelling 
to  the  side  of  the  extensor  tendons. 

Tuberculosis  often  attacks  several  of  the  metacarpal  or 
metatarsal  bones  simultaneously.  The  shafts  usually  become 
cylindrically  enlarged,  forming  the  characteristic  spina 
ventosa.     (See  Fig.  163.) 

Sacroiliac  Joint. — Sacroiliac  tuberculosis  is  especially 
important  because  of  the  semblance  its  clinical  picture 
bears  to  tuberculous  coxitis.  In  both  affections  there  is 
limping  and  apparent  lengthening  of  the  diseased  limb.  The 
former  is  distinguished  by  the  fact  that  when  the  pelvis  is 
supported  and  jfixed  the  hip-joint  movements  are  not  at  all 
restricted  nor  accompanied  by  reflex  muscular  spasm.  The 
pain  which  is  due  to  sacroiliac  disease  is  referred  to  the 
gluteal  region  and  leg,  and  is  often  enough  ascribed  to 
sciatica.  The  error  will  be  avoided  if  the  area  of  distribution 
of  the  pain  is  carefully  noted,  for  in  sacroiliac  disease  the 
pain  is  not  felt  in  the  area  supplied  by  the  sciatic  nerve. 
Furthermore  the  pain  of  sciatica  is  sharp  and  neuralgic  in 
character,  whereas  in  sacroiliac  disease  it  is  dull  and  aching, 
and,  finally,  with  sciatica  there  is  no  apparent  lengthening  of 
the  limb,  nor  local  pain  on  pressure  over  the  diseased  joint, 
nor  pain  on  pressing  together  the  iliac  crests.  Vertebral 
disease  is  easily  differentiated  from  sacroiliac  disease  if  the 
spinal  deformity,  tenderness  over  the  vertebrae,  and  limitation 
of  the  movements  of  the  spine  are  taken  into  considera- 
tion. 

Vertebral  Tuberculosis. — ^Vertebral  tuberculosis  (Pott's 
disease)  occasions  in  its  early  stages  local  pain  over  the 
diseased  bones,  referred  pain  to  the  region  which  is  supplied 
by  the  nerves  whose  roots  are  compressed  by  the  affected 
vertebrae,  painful  rigidity  of  the  spine  at  the  site  of  the 
disease,  and  an  abnormal  attitude.  When  the  disease  is 
located  in  the  dorsolumbar  region  its  early  manifestations 
are  a  "loss  of  walk"  and  a  refusal  to  stand,  and  when  the 


500     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

upper  dorsal  region  is  involved  embarrassed  respiration  is 
one  of  the  first  symptoms. 

The  location  of  the  referred  pain  naturally  varies  with 

Fig. 196 


Deformity  caused  by  persistent  sciatica  of  the  right  side.    This  attitude  is  similar  to 
that  symptomatic  of  sacroiliac  disease.    (Whitman.) 


CHRONIC  DISEASES  OF   THE  JOINTS 


501 


the  site  of  the  disease.  If  the  latter  is  in  the  lumbar  region 
the  pain  is  referred  to  the  legs ;  if  it  is  in  the  dorsilumbar  region 
the  pain  is  referred  to  the  lower  part  of  the  abdomen  and 
the  gluteal  region;  if  it  is  in  the  dorsal  region  the  pain  is 
referred  to  the  epigastrium ;  if  it  is  in  the  cervicodorsal  region 
the  pain  is  referred  to  the  arms,  and  u  it  is  in  the  upper 
cervical  region  the  pain  is  referred  to  the  region  supplied  by 
the  cutaneous  branches  of  the  cervical  plexus. 


Fig. 197 


Lumbar  disease.    Painful  rigidity  of  the  spine  illustrated  by  the  manner  of  picking 
up  an  object.    (Whitman.) 

The  painful  rigidity  of  the  spine  is  chiefly  due  to  reflex 
muscular  spasm.  In  the  dorsilumbar  region  it  can  be 
demonstrated  in  two  ways :  (1)  By  asking  the  patient  to  pick 
up  an  object  from  the  floor;  in  order  to  do  this  he  gradually 
lets  himself  down  with  an  absolutely  rigid  back  into  a  sitting 
or  squatting  position,  and  then  raises  himself  up  by  resting 
his  hands  upon  his  thighs,  thus  climbing  with  extended  arms 
up  his  own  legs;  and  (2)  by  placing  the  patient  on  a  level 


502     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

Fig. 198 


Showing  the  rigidity  of  the  spine  before  appearance  of  deformity.    (Whitman.; 


Fig. 199 


Test  for  psoas  contraction.    (Whitman.) 


CHRONIC  DISEASES  OF   THE  JOINTS 


503 


couch  with  his  face  downward,  and  then  grasping  the  ankles 
and  hfting  the  legs  from  the  table  and  from  side  to  side.  In 
a  healthy  subject  the  spine  can  thus  be  bent  back  in  the 
dorsilumbar  region  to  60  degrees,  while  lateral  mobility  to 


Fig. 200 


Disease  of  the  upper  dorsal  region.    Characteristic  attitude.    (Whitman.) 

30  degrees  or  40  degrees  on  either  side  of  the  median  line 
is  possible.  A  reflex  psoas  spasm  is  an  early  sign  of  lumbar 
Pott's  disease. 

The  attitude  in  the  early  stages  of  a  lumbar  or  lower  dorsal 
Pott's  disease  is  overerectness,  the  abdomen  being  prominent; 


504     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

the  walk  is  swaggering  or  waddling.  With  an  upper  dorsal 
Pott's  disease  there  is  a  slight  forward  inclination  of  the 
body,  the  head  being  tilted  backward  or  inclined  to  one  side, 
the  shoulders  being  elevated,  shrugging,  and  square.  With 
lower  cervical  disease  the  head  is  inclined  backward  or 
toward  one  shoulder,  while  with  upper  cervical  disease  the 
chin  is  tilted  to  one  side,  simulating  the  attitude  of  torticollis ; 
the  neck  is  stiff  and  the  patient  refuses  to  rotate  the  head, 
and  usually  supports  the  chin  on  his  hand. 

Fig. 201 


Characteristic  attitude  in  disease  of  the  middle  cervical  region  at  an  early  stage. 

(Whitman.) 


Angular  or  kyphotic  deformity  of  the  spine,  cold  abscess 
formation,  ankylosis  of  the  spine  and  in  some  cases  evidences 
of  cord  compression  are  the  additional  signs  of  spinal  tuber- 
culosis in  the  late  stages  of  the  disease. 

The  site  of  the  abscess  depends  upon  the  location  of  the 
disease.  With  cervical  Pott's  disease  a  chronic  retropharyn- 
geal abscess  is  first  formed.  This  may  burrow  downward 
into  the  mediastinum,  or  outward  into  the  posterior  or 
anterior  triangle  of  the  neck,  or  downward  and  outward 
into  the  axilla. 


CHRONIC  DISEASES  OF   THE  JOINTS 


505 


In  the  dorsal  region  the  abscess  may  point  directly  back- 
ward, or  it  may  burrow  forward  along  the  intercostal  spaces, 
or  upward  into  the  neck  or  downward  into  the  psoas  muscle. 
In  disease  of  the  dorsilumbar  or  lumbar  regions  the  abscess 
may  point  in  the  lumbar  region  and  present  superficially  in 
Petit's  triangle,  or  it  may  form  in  the  psoas  muscle,  and 


Fig. 202 


Cervical  disease.    A  characteristic  attitude.    (Wliitman.) 


thence  burrow  downward,  presenting  superficially  above 
Poupart's  ligament  to  the  outer  side  of  the  femoral  vessels  or 
below  Poupart's  ligament  to  the  inner  side  of  the  vessels. 

The  referred  pains  that  attend  early  Pott's  disease  will 
lead  to  frequent  mistakes  in  diagnosis  unless  a  careful 
examination  is  made.      In  children  especially  we  should  not 


506     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

be  too  quick  to  attribute  pains  in  the  legs  or  in  the  abdomen 
to  neuralgia  or  stomach  ache,  etc.,  but  we  should  in  every 
instance,  where  there  is  no  palpable  cause  for  the  pain, 
carefully  examine  the  spine  for  a  possible  explanation  of  it. 
The  pain  and  stiffness  that  go  with  the  early  stages  of  lumbar 

Fig.  203 


Cervical  disease  with  abscess.    Cliaracteristic  attitude.    (Whitman.) 

Pott's  disease  may  be  mistaken  for  that  which  is  due  to 
lumbago  and  sciatica;  and  the  attitude  and  gait  that  attend 
vertebral  tuberculosis  of  this  region  may  suggest  sacroiliac 
disease,  bilateral  congenital  dislocation  of  the  hip,  progres- 
sive atrophy  of  the  back  muscles,  hip-joint  disease,  and 
rachitical  spine.     Lumbago  is  an  acute  affection  of  sudden 


CHRONIC  DISEASES  OF   THE  JOINTS 


507 


onset,  and  is  usually  accompanied  by  local  pain  and  sensi- 
tiveness of  the  muscles  themselves.      In   sciatica  the  pain 


Fig. 204 


Pott's  disease  of  lumbar  vertebrfe  with  cold  abscess.    (Von  Bergmaun.) 

is  most  often  unilateral  and  is  confined  to  the  distribution  of 
the  nerve,  which  is  frequently  sensitive  to  pressure  through- 


508     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

out  its  course,  and  the  motion  of  the  spine  is  free  or  but 
sHghtly  restricted,  all  of  which  are  the  reverse  of  the  symp- 
toms of  Pott's  disease. 

In  sacroiliac  disease  the  movements  of  the  spine  are  not 

Fig. 205 


iillilkiiliiiiiliiililli 


Psoas  abscess.    (Von  Bergmann.) 


restricted,  and  the  pain  and  sensitiveness  are  usually  localized 
to  this  joint. 

In  bilateral  congenital  dislocation  of  the  hip  the  gait  and 
attitude  have  existed  since  the  child  began  to  walk  and  the 
symptoms  of  bone  disease  are  absent. 


CHRONIC  DISEASES  OF   THE  JOINTS 


509 


In  progressive  muscular  atrophy  there  are  no  evidences 
of  bone  disease. 

The  psoas  contraction  and  the  Hmp  which  accompany  some 
cases  of  himbar  Pott's  disease  are  late  manifestations,  and 
are  readily  ascertained  as  not  due  to  hip  disease  by  flexing 

Fig. 206 


Rachitic  kyphosis.    Compare  with  Fig,  207.    (Whitman.) 


the  thigh,  in  which  position  there  is  no  limitation  to  free 
movement  of  the  hip- joint  in  all  directions.  The  possible 
complication  of  hip-joint  and  lumbar  Pott's  disease  should 
be  borne  in  mind  in  those  cases  in  which  a  large  psoas 
abscess  is  present. 


510     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

The  evidences  of  general  rachitis,  the  absence  of  painful 
rigidity  of  the  spine,  and  the  rounded  character  of  the 
spinal  curvature  readily  enable  us  to  differentiate  rachitical 
deformity  of  the  spine  from  that  due  to  tuberculous  disease. 

The  stiffness  and  distortion  of  the  neck  that  attend  cervical 

Ftg. 207 


Kyphosis  from  vertebral  tuberculosis.    Compare  with  Fig.  206.    (Von  Bergmann.) 

Pott's  disease  at  once  suggest  the  different  varieties  of  torti- 
collis. In  typical  torticollis  the  distortion  of  the  head  is 
almost  invariably  caused  by  contraction  of  the  muscles 
supplied  by  the  spinal  accessory  nerve — viz.,  the  sterno- 
mastoid  and  the  trapezius;  thus  the  chin  is  slightly  elevated 


CHRONIC  DISEASES  OF   THE  JOINTS  511 

and  turned  away  from  the  contracted  muscles.  In  the 
wryneck  of  Pott's  disease  the  chin  may  be  tilted  down  or  up 
or  laterally  to  an  exaggerated  degree  and  is  turned  toward 
the  contracted  muscle,  and  the  painful  contraction  is  relieved 
if  the  head  is  supported.  Congenital  torticollis  exists  from 
birth  and  is  not  painful. 

Rheumatic  torticollis  is  of  sudden  onset  and  the  affected 
muscles  are  sensitive  to  pressure.  Acute  torticollis  accom- 
panied by  muscular  spasm  and  by  local  tenderness  some- 
times accompanies  enlarged  or  suppurating  cervical  glands, 
ear  disease,  tonsillitis,  etc.  But  this  form  of  wryneck  is  sud- 
den in  onset;  and  if  the  tension  be  relaxed  by  inclining  the 
head  toward  the  contracted  muscles,  motion  of  the  spine 
will  be  found  free  and  painless. 

Rheumatic  affections  of  the  spine  are  differentiated  from 
the  tuberculous  by  their  sudden  onset,  the  participation 
of  other  joints  in  the  disease,  and  by  their  more  painful 
character. 

Tumors  of  the  spine,  such  as  cancer  or  hydatid  cysts, 
syphilitic  disease,  and  aneurysmal  erosion  produce  symptoms 
somewhat  resembling  those  of  tuberculous  disease.  A  careful 
consideration  of  the  general  history  and  of  the  onset  of  the 
symptoms  and  a  careful  physical  examination,  aided  by  the 
test  of  treatment,  will,  in  most  cases,  enable  us  to  make  a 
diagnosis. 

Abscesses  in  the  lumbar  region  resulting  from  lumbar 
Pott's  disease  are  to  be  differentiated  from  perinephritic 
abscesses  by  the  symptoms  of  spinal  disease  and  the  absence 
of  evidences  of  renal  affection. 

Psoas  abscesses  are  differentiated  from  chronic  appen- 
dicular abscesses  by  the  presence  of  symptoms  of  spinal 
disease,  and  from  the  clinical  history  of  the  malady. 

Abscesses  due  to  disease  of  the  pelvic  bones  or  pelvic 
cellular  tissues  are  not  attended  with  the  evidences  of  spinal 
caries. 


CHAPTER   LIL 

CHRONIC  DISEASES  OF  THE  JOINTS  {Continued). 

Though  tuberculosis  is  the  most  frequent  type  of  chronic 
joint  disease,  the  occurrence  of  syphilitic,  neuropathic, 
neuralgic,  osteoarthritic,  and  hsemophilic  joint  affections  must 
not  be  forgotten. 

SYPHILITIC  JOINT  DISEASE. 

The  chronic  synovitis  due  to  syphilis  differs  in  no 
way  from  that  due  to  other  causes,  and  it  can  be  recog- 
nized only  from  the  anamnesis,  the  presence  of  other 
syphilitic  lesions,  and  by  the  exclusion  of  other  etiological 
factors.  In  the  tertiary  period  of  syphilis  localized  elastic 
nodules  (gummata)  may  form  in  the  perisynovial  fibrous 
tissue;  these  resemble  fibromata  and  occasion  a  sense  of 
painful  weakness  in  the  articulation.  Diffuse  nodulation 
with  much  thickening  and  infiltration  of  the  capsule  and 
moderate  serous  effusion  into  the  joint  may  also  occur  in  the 
tertiary  stage  of  syphilis,  and  the  cicatricial  contraction  to 
which  such  a  process  gives  rise  causes  considerable  impair- 
ment in  the  function  of  the  joint  and  often  leads  to  a  firm 
ankylosis  thereof.  The  ankylosis  may  suggest  tuberculous 
disease  of  the  joint,  but  it  differs  from  that  due  to  tuber- 
culosis in  its  firmer  and  more  painful  character,  and  its  more 
rapid  development.  The  presence  of  other  specific  lesions 
aids  in  making  the  diagnosis. 

Softening  and  erosion  of  the  articular  cartilages,  with 
eburnation  of  the  bone,  is  a  rare  result  of  syphilitic  disease; 
the  condition  bears  a  superficial  resemblance  to  osteo- 
arthritis, from  which,  however,  the  absence  of  pain  and  of 
the  characteristic  overgrowth  of  bone  and  the  slighter  grades 
of  the  destructive  process  serve  to  differentiate  it. 


CHRONIC  DISEASES  OF   THE  JOINTS 


513 


OSTEOARTHRITIS. 

The  joint  lesions  due  to  osteoarthritis  (arthritis  deformans) 
are  characterized  by  their  occurrence  usually  in  elderly 
subjects,  their  constant  progression,  and  by  the  absence  of 
suppuration  and  caries.  The  clinical  picture  is  so  typical 
that  errors  in  diagnosis  are  rarely  made.  Either  a  single  large 
joint — e.  g.,  the  hip,  the  knee,  the  elbow,  the  shoulder — or 
the  vertebral  articulations,  or  multiple   small  joints — e.  g., 

Fig.  208 


Arthritis  deformans.    Note  eulargemeut  and  thickenings  of  the  joints  and  their 
irregular  deformities. 


the  fingers  and  toes — become  painful  and  stiff  and  crepitate 
on  motion,  the  stiffness  being  especially  marked  after  the 
joint  has  been  at  rest.  The  disease  in  the  monarticular 
variety  seems  to  follow  injury;  in  the  polyarticular  variety  it 
occurs  spontaneously.  The  large  joints  become  deformed, 
somewhat  swollen,  especially  if  there  is  an  effusion  into  the 
capsule;  the  ends  of  the  bones  become  enlarged  and  the 
overlying  muscles  atrophic.  The  smaller  joints  likewise 
become  swollen,  with  marked  overgrowth  and  eburnation 
of  the  articular  ends  of  the  bones.  In  both  varieties  acute 
exacerbations  occur  from  time  to  time,  marked  by  fever, 

33 


514     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

increased  pain,  and  joint  effusion,  and  finally  the  affected 
joints  become  crippled  and  deformed. 

The  painful  character  of  the  affection;  the  stiffness  of  the 
joint,  especially  after  it  has  been  at  rest;  the  crepitus  and 
slow  enlargement  of  the  bones;  the  effusion,  and  the  absence 
of  suppuration  and  caries  should  readily  enable  one  to  make 
the  correct  diagnosis. 

Chronic  synovitis  is  not  attended  with  as  much  pain  or 
stiffness  as  is  arthritis  deformans,  and  the  effusion  is  always 
more  copious. 

Chronic  rheumatism  is  not  marked  by  the  deformity  of 
the  bones,  nor  the  crepitation,  nor  the  constantly  progressive 
character  of  arthritis  deformans. 

Gout  is  characterized  by  acute  attacks  of  joint  inflam- 
mation of  entirely  different  onset  and  clinical  history. 

Charcot's  disease  is  not  painful;  it  is  attended  with  other 
signs  of  tabes  dorsalis,  and  it  does  not  occasion  as  much  bony 
overgrowth  as  does  arthritis  deformans. 

In  the  hip-joint  the  disease  results  in  a  depression  of  the 
femoral  neck,  with  consequent  shortening  of  the  limb  and 
limitation  of  abduction.  These  symptoms  may  lead  to  a 
diagnosis  of  coxa  vara,  or  if,  as  is  frequently  the  case,  an 
injury  precedes  the  onset  of  the  malady  or  occurs  during  its 
course,  the  diagnosis  of  fracture  of  the  neck  of  the  femur 
may  be  made.  The  marked  and  continued  pain  of  arthritis 
deformans,  its  constantly  progressive  character,  and  the 
muscular  atrophy  readily  differentiate  it  from  coxa  vara,  and 
the  movement  of  the  head  with  the  shaft  of  the  bone  excludes 
fracture  unless  it  be  impacted. 

The  pain  evoked  by  movements  of  the  hip  in  sciatica  may 
possibly  suggest  arthritis  deformans.  The  differentiation  is 
readily  made  if  the  patient  is  asked  to  stand  up  and  spread 
his  legs  apart.  The  limitation  of  abduction  which  accom- 
panies arthritis  deformans  interferes  with  this  action;  further 
evidence  of  sciatica  is  afforded  in  the  distribution  of  the  pain 
along  the  posterior  aspect  of  the  thigh  and  outer  side  of  the 
leg  and  foot;  and  of  arthritis  deformans  by  the  crepitation 
and  stiffness  of  the  joint,  especially  after  rest. 


PLATE  XIX. 


Companion  plate  to  Plate  XX.  Arthritis  Deformans  at 
very  early  stage,  the  joint  thickenings  and  enlargement  of 
the  articular  ends  of  the  bone  being  very  slightly  in  evidence. 


PLATE  XX. 


Arthritis  Deformans. 

Note  the  enlargement  of  the  artieu-lar  ends  of  the  metacarpal  and 
phalangeal  bones  and  the  thickenings  around  the  joints.  Compare  with 
Plate  XIX.,  representing  the  other  hand  of  the  same  individual,  in  which 
the  lesions  were  less  marked. 


516     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

the  seat  of  recurring  attacks  of  rapid,  painless  distention, 
usually  provoked  by  slight  trauma,  with  gradual  atrophy  of 
the  bones  and  relaxation  of  the  ligaments,  in  virtue  of  which 
they  become  weakened,  flail-like  and  dislocated,  the  diagnosis 
of  neuropathic  joint  disease  is  justified.  The  above  char- 
acteristics at  once  distinguish  these  joint  lesions  from  those 
due  to  arthritis  deformans;  it  is  to  be  noted,  however,  that 
instead  of  atrophy  of  the  bones,  new  osseous  formation  may 
sometimes  occur,  leading  to  large  overgrowths  and  fixation 
of  the  joint.  The  painless  character  of  the  joint  disease  and 
the  presence  of  the  primary  affection  will  always  suffice 
to  distinguish  these  joint  diseases  from  the  other  chronic 
arthropathies. 

HEMOPHILIC  JOINTS. 

The  hoemophilic  joints  are  characterized  by  their  sudden 
onset  in  individuals  having  a  family  and  personal  history  of 
bleeding.  They  are  frequently  multiple,  tend  to  recur,  and 
arise  spontaneously  or  after  slight  injury.  The  joints  become 
swollen,  are  soft  and  doughy  at  first,  but  later  become  hard 
and  firm;  motion  is  painful  and  the  skin  is  hot. 


NEURALGIC  JOINTS. 

The  neuralgic  joints  are  encountered  chiefly  in  neurotic 
individuals,  especially  young  women.  The  deformity,  pain, 
and  wasting  of  muscles  which  accompany  them  may  strongly 
simulate  chronic  joint  disease.  On  local  examination,  how- 
ever, either  no  organic  lesions  are  found  or  only  such  as  are 
entirely  disproportionate  to  the  severity  of  the  subjective 
symptoms.  Under  anaesthesia  the  joint  moves  freely  in  all 
directions,  and  there  is  no  reflex  muscular  spasm.  A  close 
observation  of  the  patient  will  sometimes  reveal  the  fact  that 
the  vicious  position  in  which  the  limb  is  maintained  is  not  a 
constant  one,  but  varies  from  time  to  time.  It  is  to  be  noted 
that  no  other  hysterical  symptoms  may  be  present,  and  that 
the  individual  may  appear  to  be  entirely  beyond  the  pale  of 
suspicion  of  being  possessed  of  such  a  malady. 


CHRONIC  DISEASES  OF   THE  JOINTS  517 


FOREIGN  BODIES  IN  JOINTS. 

Recurrent,  sudden  attacks  of  intense  pain  in  a  joint  (the 
knee  is  the  one  that  is  most  frequently  affected)  with  its 
momentary  locking,  followed  by  a  subacute  synovitis,  are 

Fig.  210 


Free  body  in  the  knee-joint.    (Von  Bruns.) 

characteristic  of  loose  bodies  in  the  joint.  The  diagnosis  is 
verified  by  feeling  the  loose  bodies,  which  is  best  done  by 
crowding  down  the  patella  and  quadriceps  bursa  and  then 
palpating  along  the  sides  of  the  patella. 


518     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

The  attacks  are  very  similar  to  those  provoked  by  a  loose 
or  displaced  semilunar  cartilage.  The  latter  condition  is 
distinguished  by  a  longer  duration  of  the  joint  pain  and 
fixation  (in  fact,  these  last  until  the  meniscus  is  reduced),  by 
the  palpation  of  the  displaced  meniscus  and  by  the  history 
of  a  severe  injury. 


CHAPTER    LIII. 
INJURIES  OF  THE  SPINE. 

What  has  been  said  in  reference  to  the  diagnosis  of 
injuries  of  the  bones  and  joints  in  general  apphes  equally 
well  to  these  conditions  of  the  vertebrae.  The  latter  have 
an  especial  significance  only  because  they  may  be  complicated 
by  injury  to  the  spinal  cord,  its  membranes  and  nerves, 
which  complications  when  they  exist  far  outweigh  in  impor- 
tance the  lesions  of  the  osseous  and  articular  structures. 

Fracture. — It  is  a  common  belief  that  fractures  of  the  verte- 
brae are  always  attended  with  deformity  of  the  spine  and  injury 
to  or  compression  of  the  cord,  its  enveloping  membranes  and 
nerves.  As  a  matter  of  fact,  the  former  is  present  only  when 
the  fractured  bones  are  displaced,  and  the  latter  only  when 
the  cord  is  compressed  or  destroyed  or  the  seat  of  concussion. 
Even  in  extensive  fractures  there  may  be  no  displacement  of 
the  fragments  and  no  disturbances  of  the  cord;  in  such  cases 
the  diagnosis  of  fracture  rests  upon  a  history  of  trauma  and 
the  presence  of  pain,  tenderness,  crepitus,  and  abnormal  mo- 
bility over  one  or  more  vertebrae.  In  some  cases  of  vertebral 
fracture  spinal  deformity  alone  is  present.  This  is  recognized 
by  a  deviation  of  the  spinous  or  articular  processes  from  their 
normal  positions  and  by  angulation  of  the  spine.  If  such 
cases  are  first  seen  some  time  after  the  injury  has  been 
sustained  the  deformity  and  the  local  pain  and  tenderness 
may  suggest  tuberculous  or  other  organic  disease  of  the 
vertebrae. 

The  differentiation,  however,  is  readily  made  from  the 
history,  the  patient  having  been  entirely  well  prior  to  the 
reception  of  the  injury.  In  still  other  cases  of  fracture  there 
are  symptoms  of  spinal-cord  involvement  without  any  spinal 
deformity.  If  these  symptoms  develop  at  once  or  in  the  course 
of  the  first  twenty-four  hours  and  grow  gradually  worse,  they 
are  due  to  compression  of  the  cord  by  blood;  if  they  develop 


520     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

three  or  four  days  after  the  injury  they  are  due  to  inflam- 
matory exudate,  and  if  they  first  appear  some  time  after  the 
reception  of  the  injury  they  are  due  to  cicatricial  adhesions 
or  callus. 

Dislocation. — Instantaneous  death  after  a  trauma  to  the 
upper  part  of  the  neck,  or  after  hyperextension,  or  hyper- 
flexion,  or  hyperrotation  of  the  head  suggests  a  complete 
dislocation  of  the  atlas  or  axis  with  compression  of  the  cord 
or  medulla. 

Fig.  211 


Attitude  in  complete  rotary  dislocation  of  the  left  cervical  vertebrae.  Note  that  the 
neck  is  shorter  on  the  dislocated  side,  and  that  the  head  is  flexed  to  the  dislocated 
side  and  rotated  to  the  opposite  side. 


Dislocation  of  the  dorsal  and  lumbar  vertebrae  is  only  possible 
when  combined  with  fracture  of  the  articular  processes.  This 
lesion  is  readily  recognized  from  the  displacement  of  the 
articular  and  transverse  processes  and  from  the  evidences 
of  compression  of  the  cord. 

Bilateral  dislocations,  complete  and  incomplete,  and  uni- 
lateral dislocations  are  possible  in  the  lower  five  cervical 
vertebrae.  The  former  are  usually  attended  with  evidences 
of  cord  compression,  which  with  the  spinal  deformity  and 
a  sinking  of  the  head  downward  and  forward  between 
the  shoulders  indicate  the  nature  of  the  injury.  More  or 
less  fixation  and  rotation  of  the  head  to  one  or  the  other 


INJURIES  OF   THE  SPIXE 


521 


side,  the  neck  being  convex  on  one  side  and  concave  on 
the  other,  together  with  displacement  of  the  spinous  and 
lateral  processes,  point  to  a  unilateral  dislocation  upon  the 
side  of  the  convexity  of  the  neck.  The  cord  in  these  unilat- 
eral dislocations  usually  escapes  compression,  though  a 
tingling  and  neuralgic  pain  along  the  course  of  the  nerves 
may  arise  from  pressure  upon  and  stretching  of  the  nerve 
trunks  in  the  intervertebral  notches. 


Fig.  212 


1. 


Attitude  in  incomplete  rotary  dislocation  of  cervical  vertebra  (left  side).  Note  that 
the  neck  is  longer  on  the  dislocated  side  and  the  head  is  flexed  to  the  healthy  side. 
(Hoffa.) 


Injuries  of  or  hemorrhage  into  or  upon  the  spinal  cord 
and  its  nerve  roots  are  the  serious  complications  of  spinal 
injuries.  They  may  complicate  fractures  or  dislocations,  or 
occur  independently  of  these  conditions.  Every  spinal  mjury 
should  therefore  be  ^-iewed  with  suspicion  as  regards  its 
possible  effect  upon  the  cord,  and  even  in  the  absence  of 
spinal  deformity  and  other  signs  pointing  to  fracture  we 
should  be  very  cautious  in  expressing  an  opinion  as  to  the 
ultimate  consec|uences. 

Just  as  in  brain  injuries  so  in  those  of  the  cord,  the  severity. 


522     INJURIES  AND  DISEASES  OF  THE  EXTREMITIES 

extent,  and  permanency  of  the  symptoms  depend  upon  the 
character,  site,  and  cause  of  the  lesion. 

Spinal  Concussion. — Spinal  concussion  is,  like  cerebral 
concussion,  transient  in  its  immediate  effects.  Its  manifes- 
tations   are   muscular  weakness  or  paralysis,  parsesthesise. 

Fig. 213 


Attitude  in  complete  forward  dislocation  of  the  cervical  vertebrag.    (HoflFa.) 

hyperppsthesise,  or  ansesthesise.  If  these  symptoms  persist 
there  is  present  something  more  than  concussion.  Con- 
cussion may  give  origin  to  a  chronic  myelitis  (railway  spine), 
the  evidences  of  which  are  a  gradually  developing  and  slowly 
but  continuously  progressing  pain  in  the  back,  psychical  dis- 
turbances, such  as  irritability,  lack  of  energy,  and  weakness  of 


INJURIES  OF   THE  SPINE  523 

memory;  ansesthesise,  hyperaesthesise,  convulsions,  paralysis, 
etc.,  the  cerebral  symptoms  being  probably  due  to  a  coincident 
chronic  encephalitis.  The  absence  of  any  physical  evidences 
of  fracture  or  dislocation  or  of  compression  of  the  cord  may 
lead  to  such  patients  being  mistaken  for  simulants. 

Compression  of  the  Cord. — Compression  of  the  cord  is 
lasting  in  its  effects.  It  may  appear  immediately  after  the 
injury,  as  when  it  is  due  to  displacement  of  bones,  penetrat- 
ing foreign  bodies,  or  severe  intramedullary  hemorrhage,  or 
it  may  develop  after  a  shorter  or  longer  interval,  as  when  it 
is  determined  by  a  slow  extramedullary  hemorrhage,  or  an 
inflammatory  exudate,  or  callus,  or  cicatricial  adhesions 
around  the  cord  and  its  membranes.  The  symptoms  of 
compression  are  very  similar  to  those  of  destruction  of  the 
cord,  and  their  character  and  extent  depend  upon  the  nature 
and  site  of  the  lesion.  Paralysis  of  the  penile  and  perineal 
muscles  and  of  all  the  muscles  of  the  legs  except  those  sup- 
plied by  the  anterior  crural,  the  obturator,  and  the  superior 
gluteal  nerves;  anaesthesia  of  the  penis,  scrotum,  perineum, 
lower  half  of  the  gluteal  region,  and  the  whole  of  the  legs 
except  the  front  and  outer  part  of  the  thigh,  and  loss  of 
bladder  and  rectal  control  point  to  total  transverse  lesions  at 
the  upper  end  of  the  sacrum,  involving  the  cauda  equina  and 
causing  paralysis  of  the  sacral  plexus.  The  patient  lies  with 
feet  extended  (drop-foot),  but  can  move  the  thighs  and  legs. 

Complete  paralysis  of  the  muscles  of  both  limbs,  including 
those  passing  to  them  from  the  trunk;  total  anaesthesia  of 
the  legs,  gluteal  and  perineal  regions  and  possibly  the  lower 
part  of  the  abdomen,  and  complete  loss  of  control  over  the 
bladder  and  rectum  indicate  a  total  transverse  lesion  of  the 
lumbar  enlargement  of  the  cord  which  corresponds  to  the 
twelfth  dorsal  and  first  lumbar  vertebrae.  The  patient  lies 
with  the  thighs,  legs,  and  feet  extended. 

The  same  phenomena  with  a  more  extensive  region  of 
anaesthesia,  limited  above  by  a  hyperaesthetic  zone  which  feels 
like  a  tight,  painful  girdle  around  the  waist,  and  paralysis 
of  the  abdominal  muscles  indicate  a  transverse  lesion  in  the 
mid-dorsal  region.  There  is  no  tendency  to  drop-foot  and 
the  limbs  offer  some  resistance  to  passive  motion,  the  tendon 
reflexes  being  exaggerated  and  the  muscles  somewhat  rigid 


524     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

unless  there  has  been  a  total  destruction  of  the  cord,  under 
which  circumstances  the  muscles  are  relaxed  and  the  tendon 
reflexes  lost. 

The  same  phenomena  with  paralysis  of  the  spinal  and 
intercostal  muscles,  with  anaesthesia  of  nearly  the  whole 
trunk,  the  hypereesthesia  possibly  involving  the  arms,  and 
with  priapism,  indicate  a  total  transverse  lesion  in  the  cer- 
vicodorsal  region.  The  hands  are  in  a  position  of  main  en 
griff e,  but  the  elbows  and  shoulders  can  be  freely  moved. 

The  same  phenomena  with  the  paralysis  and  anaesthesia 
extending  to  the  arms  indicate  a  lesion  in  the  lower  cervical 
region.  If  the  seventh  cervical  segment  is  destroyed  the 
forearms  are  partially  flexed  and  lie  upon  the  body  with  the 
hands  pronated.  Voluntary  movements  of  the  wrist  are 
impossible,  but  the  elbow  and  shoulder  can  be  moved.  If 
the  sixth  cervical  segment  is  involved  the  arms  are  abducted 
from  the  side,  the  forearms  are  supinated,  and  the  wrist  and 
fingers  are  paralyzed.  If  the  fifth  cervical  segment  is  involved 
the  arms  lie  extended  and  relaxed  at  the  side  of  the  body, 
all  motion  being  impossible. 

Partial  paralyses  in  the  area  of  distribution  of  the  spinal 
nerves  point  to  incomplete  transverse  lesions;  and  motor 
paralysis  on  the  injured  side  with  sensory  paralysis  on  the 
opposite  side — i.  e.,  Brown-Sequard  paralysis— points  to  hemi- 
trans verse  lesions.  With  the  lesser  degrees  of  compression  or 
destruction  the  motor  paralyses  are  more  in  evidence  than 
the  sensory;  in  fact,  the  latter  may  be  altogether  absent. 

In  determining  the  exact  level  of  the  lesion  in  the  cord  we 
are  guided  chiefly  by  the  area  of  anaesthesia.  It  is  important 
to  remember  in  this  connection  that  the  level  of  the  lesion 
should  always  be  placed  one  segment  higher  than  appears 
to  be  the  case  from  the  area  of  anaesthesia.  The  muscles 
which  are  the  seat  of  flaccid  paralysis  and  atrophy,  and 
which  show  reaction  of  degeneration  and  loss  of  reflex  action, 
also  guide  us  to  the  level  of  the  lesion.  The  character  of  the 
lesion  is  often  very  difficult  to  determine.  If  the  symptoms 
come  on  gradually  during  the  first  twenty-four  hours  after 
the  injury  the  lesion  is  probably  a  compression  by  a  blood 
clot.  Whether  in  the  other  cases  the  lesion  is  a  compression 
or  destruction  can  only  be  determined  by  operation. 


PLATE  XXI. 


Defect  in  the  Vertebrae,  allowing  a  Protrusion  of  the  Spinal 
Cord  and  Membranes. 


CHAPTER   LIV. 

TUMORS  IN  THE  SPINAL  REGION. 

A  TUMOR  in  the  middle  line  of  the  back,  most  commonly 
at  the  lower  end  of  the  spine  in  a  newborn  babe,  that  can 
be  made  smaller  by  compression,  that  has  an  impulse  on 
crying  and  straining,  and  at  whose  base  the  outlines  of  a 
defect  in  the  vertebrae  can  be  made  out  is  a  spina  bifida — 

Fig. 214 


;      Vaacular  medullary  area. 
Serous  epithelial  zone. 

Myelomeningocele.    (Von  Bergmann.) 


i.  e.,  a  hernial  protrusion  of  the  cord  and  its  membranes. 
If  the  tumor  has  a  broad  base,  and  if  at  the  centre  of  its 
surface  there  is  an  elongated,  rounded  white  area  without 
skin  (the  medullovascular  zone)  surrounded  by  a  pearl-gray, 
glistening  zone  of  irregular  shape  which  merges  into  a  zone 
of  normal  skin  covered  by  fine  hairs,  it  is  a  myelomeningocele. 
Such  tumors  are  frequently  associated  with^  paraplegia  and 


526     INJURIES  AND  DISEASES  OF   THE  EXTREMITIES 

other  congenital  malformations,  such  as  club-foot,  hernia,  etc. 
If  the  tumor  is  of  mushroom-shape  and  is  covered  by  normal 
or  thickened  skin,  beneath  which  there  may  be  a  lipoma, 
and  if  it  is  fluctuant  and  translucent,  it  is  a  meningocele,  a 
rather  infrequent  form  of  spina  bifida.  If  the  tumor  has  a 
broad  base  and  is  covered  with  skin  that  appears  normal 
at  the  margins  of  the  tumor,  and  becomes  thinner  and 
thinner  toward  its  centre,  where  it  is  translucent,  glistening, 

Fig. 215 


Meningocele.    Before  operation.    (Von  Bergmann.) 


and  of  grayish  color,  it  is  a  myelocystocele;  if  such  a  tumor 
contains  considerable  fluid  it  is  a  myelocystomeningocele. 
The  absence  of  a  medullovascular  zone  distinguishes  these 
latter  forms  of  spina  bifida  from  the  myelomeningocele. 
Should  the  thin  cutaneous  covering  of  a  myelocystocele 
ulcerate,  the  ulcerated  area  will  have  some  resemblance  to 
the  medullovascular  zone  of  a  myelomeningocele,  and  so 
lead  us  to  a  wrong  classification  of  the  tumor.     But  the 


TUMORS  IN   THE  SPINAL  REGION  527 

history  that  the  ulceration  first  appeared  some  time  after  the 
birth  of  the  child,  and  the  infrequent  association  of  other 
congenital  malformations  with  the  myelocystomeningocele, 
will  enable  us  to  distinguish  between  these  two  forms  of 
spina  bifida. 

A  tumor  that  develops  in  later  life  in  the  middle  line  of 
the  back,  usually  over  the  sacral  region,  that  is  rounded, 
smooth,  and  somewhat  elastic,  and  that  is  covered  by  normal 
skin,  is  a  dermoid  cyst.  This  type  of  tumors  may  also  develop 
in  the  remains  of  the  neurenteric  canal,  in  which  case  they 
are  located  between  the  rectum  and  coccyx  and  project 
inward  toward  the  rectum  or  downward  toward  the  coccyx, 
or  backward  toward  the  sacrum,  even  protruding  outside  of 
the  pelvis  through  the  sciatic  foramina. 


INDEX. 


Abdomen,  contusions  of,  235 
method  of  examination  of,  222 
succussion  over,  229 
wounds  of,  235 
Abdominal    diseases,    fluoroscopy 
in,  223 
palpation,  224 

tumors,   distention  of  colon  in, 
229 
mobilityof,  227 
viscera,  injuries  of,  235 
wall,  abscess  of,  232 

cutaneous  veins  of,  in  portal 
vein  obstruction,  223 
in  vena  cava  inferior  ob- 
struction, 223 
cysts  of,  234  _ 
fat  accumulation  on,  signs  of, 

223 
hsematoma  of,  231 
irregularities  of,  235 
movements  of,   with  respira- 
tion, 223 
neoplasms  of,  231 
oedema  of,  signs  of,  223 
rigidity  of,  226 
rupture  of  muscles  of,  232 
scars  and  striae  on,  227 
tumors  of,  233 
Abnormal  lobes  of  Uver,  300 
Abscess  of  abdominal  wall,  232 
in  appendicitis,  2S9 
of  brain,  79 
interloVjar,   195 
of  kidney,-  386 
of  liver,  303 
of  lung,  198 
of  pancreas,  326 
of  parotid  gland,   120 
of  retropharynx,  124 


Abscess  of  spleen,  339 

subphrenic,  194,  255 

of  tonsil,   112 
Actinomycosis  of  ceecum.  297 

of  cellular  tissue,  127 

leukocyte  count  in,  42 

of  pharynx,   112 

of  thoracic  wall,   178 

of  ton2;ue,   108 

of  tonsil,   112 
Adenoids  of  nasopharynx,  112 
Adenoma.     See  Tumors. 
Adrenal  bodies,  neoplasms  of,  400 
Air  passages,  foreign  bodies  in,  163 
Anaemia.     See  Blood. 
Aneurysm,     aortic,     differentiated 
from  pulsating  empyema,  197 

of  vessels  of  neck,  145 
of  skull-bones,  64 
Angina  Ludovici,  117,  123 
Angioma  of  neck,  145 
Ankle-joint,  dislocation  of,  480 

fracture  of  bones  of,  480 

injuries   of,    method   of   exami- 
nation of,  480 

tuberculosis  of,  498 
Anthrax,   126 
Aortic      aneurysm     differentiated 

from  pulsating  empyema,  197 
Aphasia  in  cerebral  diseases,  76 

optical,  80 
Aphthae,  104 

Appendicitis,  abdominal  wall  rigid- 
ity in,  288 

abscess  in,  289 

chiU  in,  287 

diagnosis  of,  286 
differential,  292 
difficulty  of,  285 

diseases    of    caectun   simulating, 
294 

follicular  (catarrhal),  acute,  280 _5 


34 


530 


INDEX 


Appendicitis,  follicular,  chronic,288 
gangrenous,  acute,  288,  289 
general  appearance  of  patient  in, 

287 
leukocyte  count  in,  41,  289 
mesenteric     and     portal    vein, 

thrombosis  in,  291 
pulse  rate  in,  286 
pyaemia  in,  290 
septicsemia  in,  290 
temperatures  in,  286 
ulcerative,  acute,  288,  289 

Appendix,  method  of  palpation  of, 
285 
perforation  of,  278 
site  of,  285 

Ascites,  shifting  dulness  in,  252 
signs  of,  223,  252 
umbilicus  in,  252 
varieties  of,  253 

Astragalo-calcanean    joint,    tuber- 
culosis of,  499 

Ataxia  in  cerebral  diseases,  76 

Atresia  of  rectum,  363 

Atrophy  of  prostate  gland,  415 


B 


Basophiles,  38 
Bile-ducts,  neoplasms  of,  323 
Bladder,   calculus  in,  404,  407 
carcinoma  of,  404,  407 
diseases  of,  cystoscopy  in,  405 

frequency  of  urination  in,  404 

hsematuria  in,  405 

pain  in,  403 

pyuria  in,  404 

symptoms  of,  403 

tenesmus  in,  403 
exstrophy  of,  231 
inflammation  of,  404,  406 
injuries  of,  408 
muscular  walls  of,   changes  in, 

from  arteriosclerosis,  418 
neoplasms  of,  407 
papilloma  of,  404,  407 
perforation  of,  278 
tuberculosis  of,  403,  406 
Blood,  anaemia,  37,  38 

in  malignant  diseases,  38 
cells,  method  of  staining,  37 

red,  method  of  counting,  36 
varieties  of,  37 


Blood  cysts,  144 
haemoglobin,  35 

leukocytes,  method  of  counting, 
36 
number  of,  in  actinomycosis, 
42 
in  appendicitis,  41,  289 
in  inflammation    of    bones, 
40 
of  serous  membranes,  40 
of  soft  parts,  39 
in  injuries,  42 
in  intra-abdominal  diseases, 

41 
in  leukaemia,  37 
in  neoplasms,  42 
in  tuberculosis,  42 
varieties  of,  37 
Bones,  echinococcus  cyst  of,  454 
medullary  tumors  of,  452 
neoplasms  of,  449,  451 
syphiUs  of,  448 
tuiaerculosis  of,  444,  448 
Brain,  abscess  of,  79 

neoplasms  of,  85 
Branchiogenetic  cysts,  139 
Breast,  eczema  of  nipple  of,  191 
hypertrophy  of,   185 
inflammation  of,  183 
method  of  examination  of,   183 
neoplasms  of,   185 
Paget's  disease  of,  191 
suppuration  of,  184 
syphilis  of,  185,  191 
tuberculosis  of,  185 
Broad  ligament,  tumors  of,  355 
Bronchi,  compression  of,  202,  204 
foreign  bodies  in,  163 
perforation   into,    of   echinococ- 
cus cyst,  203,  308 
of  liver  abscess,  305 
of  pulmonary  abscess,  196 
traction  diverticula  of,  205 
tumors  of,  202 
Brown-Sequard  paralysis,  524 
Bryant's  iliofemoral  triangle,  475 
Bursitis,  subhyoid,  144 


Cachexia,  23 

Caecum,  actinomycosis  of,  297 
diseases  of,  simulating  appendi- 
citis, 294 


INDEX 


531 


Caecum,  distention  of,  in  intestinal 

obstruction,  282 
Calculi  in  bladder,  404,  407 

in  kidne}',  395 

in  pancreas,  338 

in  parotid  gland,  118 

in  prostate  gland,  418 

in  salivar}^  glands,   118 

in  urethra,  418 
Cancer.     See  Tumors. 
Caput  medusie,  223 

succedaneum,  53 
Carbuncle,   126 
Carcinoma.     See  Neoplasm. 

of  bladder,  404,  407 

of  kidney,  399 

of  lymphatic  glands,  137 

of  tongue,   109 

of  tonsil,   115 
Cardiospasm,  213 
Catarrhal  appendicitis,  acute,  280 
Cellular  tissue,    actinomycosis   of, 

127 
Cephalhsematocele,  55 
Cephalhsematoma,  53,  63 
Cerebral   abscess,   McEwen's   sign 
in,  80 

diseases,  aphasia  in,  76 
ataxia  in,  76 

laceration,  68 

localization,  70 
Cerebrum,  compression  of,  67 

concussion  of,  66 

injuries  of,  65 
coma  from,  69 
differential    diagnosis    of,  69, 
70 

laceration  of,  68 

tumors  of,  85 

differential  diagnosis  of,  86 
Jacksonian  epilepsy  in,  87 
nature  of,  87 
symptoms  of,  focal,  87 
general,  85 
Cervical  ribs,   147 
Chancre  of  external  genitals,  423 

of  face,  88 

of  penis,  423 
Charcot's  joint  disease,  514 
Chevne-Stokes  breathing,  76 
Cholangitis,  318 
Cholecystitis,  317 
Cholelithiasis,  colic  from,  315 

Courvoisier's  law  in,  25,  322 

diagnosis  of,  319 


Cholelithiasis,  diagnosis  of,  differ- 
ential, 320 
icterus  in,  316 

impaction  of  gallstones  in,  316 
infection  of  gall-bladder  in,  317 
Riedel's  lobe  in,  312 
site  of  forination  of  gallstones  in, 

315 
symptoms  of,  315 
Clavicle,  fracture  of,  437 
CoUes'  fracture,  474 
Colon,  distention  of,  in  abdominal 
tumors,  229 
method  of,  228 
Compression  of  brain,  67 
Concussion  of  brain,  66 
Condylomata  of  penis,  424 
Contusions  of  abdomen,  235 
Cord,    spermatic.      See   Spermatic 
cord, 
hsematocele  of,  427 
hydrocele  of,  426 
spinal.     See  Spinal  cord. 
Courvoisier's  law  in  cholelithiasis, 

25,  322 
Cowper's  gland,  cyst  of,  419 
Coxa  vara,  495,  497 
Cranial  hernife,  53 

differential  diagnosis  of,  56 
nerves,  injuries  of,  68 
Croup,   162 
Cryoscope,  22,  378 
Cryoscopy.     See  Kidney. 
Cryptogenetic  septicaemia,  47 
Cystoscope,  21 

contraindications     to     emploj- 

ment  of,  in  vesical  diseases,  405 

Cystoscopic  pictures  in  calculi  of 

bladder,  407 

in  carcinoma  of  bladder,  407 

in  cystitis,  406 

in  papilloma  of  bladder,  407 

in  tuberculosis  of  bladder,  406 

Cystoscopy  in  vesical  diseases,  405 

contraindications  to,  405 
Cysts  of  abdominal  wall,  234 
blood,   144 
branchiogenetic,   139 
of  Cowper's  gland,  419 
dentigerous,  of  maxillarv  bones, 

95,  96 
echinococcus,  of  kidney,  400 
of  liver,  306 
of  lung,  202 
of  mesentery,  298 


532 


INDEX 


Cysts,  echinococcus,  of  neck,  144 
of  kidney,  400 
of  liver,  311 
of  mesentery,  298 
of  pancreas,  328 
of  sacral  region,  527 
of  scalp,  58 
sebaceous,  of  scalp,  58 


D 


Diabetes,  traumatic,  76 
Diaphragm,  injuries  of,  176 
Dilatation  of  CBsophagus,  210,  216 
Diphtheria  of  larynx,  162 
Dislocation  of  ankle-joint,  480 

of  elbow-joint,  470 

of  hip-joint,  476,  496 

of  knee-joint,  479 

of  shoulder- joint,  468 

of  temporomaxillary  joint,  92 

of  vertebrae,  520 

of  wrist-joint,  474 
Diverticulum  of  oesophagus,  212 
Donne's  test  for  pus  in  urine,  404 
Dotter's  fistula,  240 
Duodenum,  perforation  of,  277 
Dura  mater,  neoplasms  of,  63 


E 


Echinococcus  cyst  of  bones,  454 
characteristics  of,  308 
fremitus  in,  226,  307 
of  kidney,  400 
of  liver,  306 

characteristics  of,  307 
differential  diagnosis  of,  308 
fremitus  in,  307 
icterus  with,  307 
infection  of,  308 
rupture  of,  308 
of  lung,  202 

perforation  of,  203 
of  mesentery,  298 
of  neck,   144 
Eczema  of  nipple,  191 
Egg-shell  crackle  in  tumors  of  me- 
dulla of  bone,  99 
Elbow-joint,  carrying  angle  of,  469 
dislocation  of,  470 
examination  of,  469 
fractures  of,  472 


Elbow-joint,  inflammation  of.     See 
Joints, 
relations     of      bony     processes 

around,  469,  473 
tuberculosis  of,  490 
Emaciation,  significance  of,  23 
Emphysema  of   cellular  tissue   of 

thorax,   173 
Empyema  of  frontal  sinus,  97 
of  gall-bladder,  317 
of  pleura,  192 

differential  diagnosis  of,  194 
leukocyte  count  in,  192 
physical  signs  of,  193 
pulsating,   197 
sacculated,   195 
pulsating,     differentiated     from 

aortic  aneurysm,  197 
of  sinus  of  maxillary  bones,  97 
Encephalitis,  suppurative,  acute, 79 
chronic,  79 

differential  diagnosis  of,  80 
localization  of,  81 
optical  aphasia  in,  81 
Encephalocele,  55 

characteristics  of  fluid  in,  57 
differential  diagnosis  of,  56 
sites  of,  54 
varieties  of,  55 
Encysted  hernia,  430 
Eosinophils,  38 

Epididymis,  inflammation  of,  432 
syphilis  of,  433 
tuberculosis  of,  434 
Epilepsy,  Jacksonian,  87 
Epispadias,  423 
Epuhs,  97 

Erysipelas,   constitutional  symp- 
toms of,  44 
local  lesion  of,  50 
Ewald's  sign  of  hour-glass  stomach, 

273 
Examination  of  abdomen,  222 
Exostoses,  451 

Exploratory  laparotomy  in  obscure 
abdominal  diseases,  219 
puncture  in  diseases  of  internal 
organs,  230 
Exstrophy  of  bladder,  231 
Extrauterine  pregnancy,  decidual 
discharge  in,  351 
differential  diagnosis  of,  353 
rupture  of,  352 
symptoms  of,  351 
tubal  mole,  351 


INDEX 


533 


Face,  chancre  of,  88 
neoplasms  of,  89 
syphilis  of,  88 
Fallopian  tube,  infianimations  of, 
349 
differential  diagnosis  of,  349 
method     of    examination    of, 

343 
position    of,   when    inflamed, 
349 
Femoral  hernia,  238 
Femur,  fracture  of,  438,  477 
Fever,  causes  of,  32 

in  relation  to  pulse  and  respira- 
tion rate,  34 
subnormal,  35 

in  collapse,  35 
types  of,  33 
Fibroma.     See  Tumors. 
Fibula,  fracture  of,  438,  480 
Fistula  in  ano,  368 
branchial,   156 
Dotter's,  241 
in  rectum,  368 
urinary,  409 
Floating  liver,  302 
Fluoroscopy  in  abdominal  diseases, 

223 
Foreign  bodies  in  air  passages,  163 
in  bronchi,  163 
in  larynx,  163 
in  trachea,  163 
Fracture  of  bones  of  ankle-joint, 
480 
of  clavicle,  437 
Colics',  474 
of  elbow-joint,  472 
of  femur,  438,  477 
of  fibula,  438,  480 
of  humerus,  437,  469,  472 
of  malar  bone,  91 
of  maxillary  bones,  91 
methods  of  examination  for,  436 
of  patella,  438,  479 
of  radius,  438,  473 
of  ribs,   172 
signs  of,  435 
of  sternurn,   172 
of  tibia,  438,  480 
of  ulna,  438,  472 
of  vertebrae,  519 
Frontal  sinus,  empyema  of,  97 
Furuncle,"  126 


Gall-bladder,  empyema  of,  317 

enlargement  of,  differential  diag- 
nosis of,  320 
physical  signs  of,  316 

gangrene  of,  317 

hydrops  of,  317 

inflammation  of,  317 

neoplasms  of,  322 

palpation  of,  314 

perforation  of,  278 

position  of,  314 
Gangrene  of  lung,  198 
Gangrenous   appendicitis,    acute, 

288,  289 
Gastrodiaphane  in  diseases  of  stom- 
ach, 223 
Genitals,  external,  chancre  of,  423 
Gerster's  position,  224 
Gland,  Cowper's,  cyst  of,  419 
Glenard's  disease,  383 
Glottis,  oedema  of,  162 
Goitre.     See  Thyroid  gland. 
Gumma.     See  Syphilis. 


H 


HjEMAtocele  of  spermatic  cord,427 
of  tunica  testis,  427 

Hsematoma  of  abdominal  wall,  231 
of  spermatic  cord,  427 
of  urethra,  420 

Hgematuria,  405,  412 

in  tumors  of  kidney,  398 
vesical,  differentiated  from  ure- 
thral and  renal,  405 

Head,  injuries  of,  65 
zones,  30 

Heart,  injuries  of,  174 

Hegar's  method  of  palpating  ped- 
icle of  uterine  and  ovarian  tu- 
mors, 344 

Hemarthroses,  467 

Hemian£esthesia  in  cerebral  dis- 
eases and  injuries,  75 

Hemianopsia  in  cerebral  diseases 
and  injuries,  75 

Hemiplegia  in  cerebral  diseases 
and  injuries,  71 

Hemocytometer,  22 

Heinoglobinometer,  22 

Hemophilia,  joint  effusion  in,  516 

Hemorrhoids.     See  Rectum. 


534 


INDEX 


Hernia,  contents  of,  appendix,  243 
bladder,  243 
diseases  of,  243 
intestines,  243 
liver  and  spleen,  243 
omentum,  243 
ovary  and  testicle,  243 
torsion  of,  245 
cranial,  53 

differential     diagnosis    of,     epi- 
gastric, 241 
of  femoral,  247 
of  inguinal,  246 
of  obturator,  239 
of  umbilical  cord,  239 
of  ventral,  lateral,  242 
encysted,  430 
femoral,  238 
inflammation  of,  244 
inguinal,  237 

properitoneal,  237 
superficial,  237 
irreducible,  244 
of  lung,  178 
obstruction  in,  244 
obturator,  238 
strangulation  of,  245 
through  laparotomy  scars,   242 
linea  semilunaris, '  242 
Petit's  triangle,  242 
umbilical;  239 

into  umbilical  cord,  239 
ventral,  241 

diastasis  of  recti  muscles,  241 
epigastric,  241 
Herpes  of  penis,  425 
Hip-joint,  dislocation  of,  476,  496 
examination  of,  475 
signs  of  fluid  in,  459 
tuberculosis  of,  491 
cold  abscess  in,  491 
differential  diagnosis  of,  493 
position  of  limb  in,  491 
Hour-glass  stomach,  273 
Humerus,  dislocation  of,  468 
fracture  of,  437,  469,  472 
musculospiral     paralysis     in, 
438 
Hydrocele,  427 

of  spermatic  cord,  427 
of  tunica  testis,  429 
Hydronephrosis,  388 
Hydrophobia,  45 
Hydrops  of  gall-bladder,  317 
of  joints,  457 


Hydrops  of  maxillary  bones,  94 
sinus,  94 

differential  diagnosis  of,  95 
Hydrosalpinx,  349 
Hygroma  colli,  142,  144 
Hypernephrosis,  399 
Hyperplasia  of  lymphatic  glands, 
132 
of  tonsil,  112 
Hypertrophy  of  breast,  185 

of  prostate  gland,  415 
Hypospadias,  423 


Icterus  in  cholelithiasis,  316 
in  common  bile-duct  obstruction 
by  calculus,  317 
by  tumor,  327 
hsemohepatogenous,  23 
obstructive,  23 
with  cholangitis,  318 

distended  gall-bladder,  316 
Incontinence  of  urine,  410 
Inflammation  of  bones,  leukocyte 
count  in,  40 
of  breast,  183 
of  epididymis,  432 
of  Fallopian  tube,  349 
of  gall-bladder,  317 
of  hernia,  241 
of  larynx,   161,  165 
of  maxillary  bones,  92 
of  ovaries,  chronic,  354 
of  parotid  gland,   120 
of  prostate  gland,  413 
of  rectum,  366 
of  salivary  glands,  117 
of  serous  membranes,  leukocyte 

count  in,  40 
of  soft  parts,  leukocyte  count  in, 

39 
of  testicle,  432 
of  tongue,   106 
of  ureter,  401 
of  urethra,  413 
Inguinal  hernia,  237 
Interlobar  abscess,  195 
Intestinal  bruits,  229 

obstruction,    diagnosis   of,    281, 
284 
differential,  282 
distention  of  caecum  in,  282 
fixed  coil  in,  282 


INDEX 


535 


Intestinal    obstruction,    intestinal 
erections  in,  283 
leukocyte  count  in,  41 
objections  to  use  of  cathartics 

in,  280 
symptoms  of,  280,  283 
types  of,  281 
Intestines,     mesentery     of,     neo- 
plasms of,  298 
small,  neoplasnis  of,  296 
tuberculosis  of,  297 
Intussusception,  282,  284,  364 
Irreducible  hernia,  244 


Jaboulay's     sign     of     hour-glass 

stomach,  273 
Jacksonian  epilepsy,  87 
Jaw  bones,  osteomyelitis  of,  92 
Jaworski's  sign  of  hour-glass  stom- 
ach, 272 
Joints,  contour  in  diseases  and  in- 
juries of,  456 
cutaneous   covering   in   diseases 

and  injuries  of,  456 
diseases  of,  arthritis,  482 
in  hfemophilia,  516 
in  hysteria,  516 
in  organic  nervous  disease, 

515 
osteoarthritis,  513 
sympathetic    or    collateral , 

483 
syphilitic,  512 
tuberculous,  482,  484 
differential   diagnosis   of, 

487 
symptoms  of,  484 
synovitis,  481 

catarrhal,  443,  483 
general  considerations  on  diag- 
nosis in  diseases  and  injuries 
of,  455 
hydrops  of,  457 
injuries  of,  467 
measurement  of  limb  in  diseased 

and  injuries  of,  462 
motion  in  diseases  and  injuries 

of,  462 
muscular  atrophy  in  diseases  and 

injuries  of,  457 
relation  of  bony  points  around, 
461 


Joints,  signs  of  fluid  in,  457 
tuberculosis  of,  485 
x'-ray  examination  in  disease  and 
injury  of,  463 


Kidney,  abscess  of,  acute  miliary, 
386 
chronic,  386 

differential  diagnosis  of,  388 
absence  of,  382 
anamnesis  in  diseased  conditions 

of,  369 
calculus,  395 

acute  hydronephrosis  in,  396 

anuria  in,  396 

associated   with   pyelitis   and 

pyonephrosis,  391 
colic  in,  396 

differential  diagnosis  of,  397 
diagnosis  of,  differential,  395 

x-ray  in,  395 
ureteral  orifice  in,  375,  396 
carcinoma  of,  399 
cysts  of,  400 
echinococcus  cyst  of,  400 
function  of,  378 

determination  of,  Beckmann's 
apparatus  for,  379 
cryoscopy  for,  378 
methylene  blue  test  for,  381 
phloridzin  test  for,  381 
urea  percentage  for,  378 
individual  and  combined,  378, 
380 
fusion  of,  382 
hydronephrosis  of,  388 

differential  diagnosis  of,  389 
ureteral  efflux  in,  389 

orifice  in,  389 
urine  in,  389 
injuries  of,  235 
neoplasnis  of,  398 
palpation  of,  372 
position  of,  371 

relation  of,  to  colon  and  stom- 
ach, 371,  372 
sacral,  382 
ptosis  of,  382 
puncture  of,  373 
pyonephrosis  of,  389 

differential  diagnosis  of,  389 
ureteral  efflux  in,  389 


536 


INDEX 


Kidney,  pyonephrosis,  ureteral  ori- 
fice in,  389 

urine  in,  389 
sarcoma  of,  399 
tuberculosis  of,  391 

differential  diagnosis  of,  393 

symptoms  of,  391 

ureteral  orificial  appearance 
in,  376,  392 
tumors  of,  character  of,  398 

cystic,  399 

hematuria  in,  398 

symptoms  of,  398 

ureteral  orifice  in,  375,  376 

urine  in,  398 

varieties  of,  398 
x-ray  examination  of,  376 
Knee-joint,  dislocation  of,  479 
examination  of,  478 
fracture  of  bones  of,  479 
range  of  motion  in,  479 
rupture  of  ligaments  of,  479 
tuberculosis  of,  497 


Laryngismus  stridulus,  162 
Larynx,  compression  of,  170 

diphtheria  of,  162 

examination  of,   158 

foreign  bodies  in,  163 

inflammation  of,  161,  165 
of  cartilages  of,  169 

injuries  of,  165 

neoplasms  of,  167 

oedema  of,  162 

pachyderma  of,  168 

spasm  of,  162 

stenosis  of,  161 

stricture  of,  169 

symptoms  of  disease  of,  160 

syphilis  of,  166 

tuberculosis  of,  166 
Lenhardtz's  kernels,  202 
Leuksemia,  135 

of  lymphatic  glands,  135 
■  spleen  in,  341 
Leukocytosis,  39 

in  actinomycosis,  42 

in  inflammation  of  bones,  40 
of  serous  membranes,  40 
of  soft  parts,  39 

in  injuries,  42 

in  intra-abdominal  conditions,41 


Leukocytosis  in  neoplasms,  42 

in  tuberculosis,  42 
Lipoma  of  spermatic  cord,  428 
Liver,  abnormal  lobes  of,  300 

differential     diagnosis     of, 

301 
physical  signs  of,  301 
symptoms  from,  301 
torsion  of,  301 
abscess  of,  303 

characteristics     of     pus    in, 

304 
differential  diagnosis  of,  305 
enlargement  of  liver  in,  303, 

304 
exploratory  aspiration  in,  303, 

304 
leukocyte  count  in,  304 
multiple,  causes  of,  304 
symptoms  of,  304 
temperature  with,  304 
perforation  of,  304 
pleural  effusion  with,  304 
tropical,  jaundice  with,  303 
symptoms  of,  302 
temperature  with,  303 
tenderness  with,  303 
concentric   obliteration   of    dul- 

ness  of,  229 
congenital  malposition  of,  302 
cysts  of,  311 

echinococcus,  306 
floating,  302 
injuries  of,  235 
position  of,  300 
syphilis  of,  312 
tumors  of,  306 
cystic,  311 
solid,  311 
Ludloff's  signs  of  early  articular 

tuberculosis,  463 
Lung,  abscess  of,  198 
bacteria  in,  200 
diagnosis  of,  201 
expectoration  in,   199 
physical  signs  of,  199 
Roentgen  ray  examination  m, 
200 
echinococcus  cyst  of,  202 
gangrene  of,  198 
hernia  of,  178 
injuries  of,  173 
neoplasms  of,  202 
tumor  of,  202 
Lupus  vulgaris,  88 


INDEX 


537 


Lymphangioma  colli,  143 

Lymphatic  glands,   carcinoma  of, 
137 
leuka?mia  of,  135 
neoplasms  of,  135,  137 
pseudoleukaemia  of,  133 
sarcoma  of,  135,  137 
simple  hyperplasia  of,  132 
syphilis  of,  136 
tuberculosis  of,  132,  136 


M 


Malar  bone,  fracture  of,  91 
Mastitis.     See  Breast. 
Maxillarjr  bones,  cysts  of,  95,  96 
dislocation  of,  92 
empyema  of,  97 
fracture  of,  91 
hydrops  of,  94 
inflammations  of,  92 
neoplasms  of,  97 
sinus,  empyema  of,  97 
hj^drops  of,  94 
McE wen's  sign  in  cerebral  abscess, 
80 
in  meningitis,  78 
Mediastinum,  enlarged  glands  in, 
205 
neoplasms  in,  205 
suppuration  in,  207 
symptoms  and  physical  signs  of 
disease  in,  204 
Medullary  tumors  of  bones,  452 
of  maxillse,  99 

differentiation  of,  101 
Megaloblasts,  37 
Meltzer's  position,  224 
Meningitis,  character  of  spinal  fluid 
in,  78 
McEwen's  sign  in,  78 
Meningocele,  55,  526 
Mesentery,  cysts  of,  298 

echinococcus  cyst  of,  298 
Myelocj'stomeningocele,  526 
Myelomeningocele,  525 
Microblasts, ,  37 
Mouth,  syphiUs  of,  105 
Movable  spleen,  339 
Moynihan's     sign     of     hour-glas? 

stomach,  272 
Muscular  rigidity,  30 
Musculospiral  paralysis,  438 


N 


Nasopharynx,  adenoids  of,   112 
Neck,  angioma  of,  145 

echinococcus  cyst  of,  144 

neoplasms  of,   130 

vessels  of,  aneurj^sm  of,  145 
Neoplasm     of     abdominal     wall, 
231 

of  adrenal  bodies,  400 

of  bile-ducts,  323 

of  bladder,  407 

of  bones,  449,  451 

of  brain,  85 

of  breast,  185 

of  dura  mater,  63 

of  face,  89 

of  gall-bladder,  322 

of  genital  organs,  external,  423 

of  kidney,  398 

of  larynx,   167 

leukocyte  count  in,  42 

of  lung,  202 

of  lymphatic  glands,  135,  137 

of  maxillary  bones,  97 

of  mediastinmn,  197,  205 

of  mesentery  of  intestine,  298 

of  neck,  130 

of  oesophagus,  211,  217 

of  omentum,  299 

of  ovaries,  354 

of  pancreas,  328 

of  parotid,   121 

of  pharynx,   115 

of  prostate,  418 

of  rectum,  367 

of  retrotonsillar  lymphatic 
gland,   115 

of  scalp,  59 

of  skuU,  63 

of  small  intestine,  296 

of  stomach,  265 

of  testicle,  434 

of  thoracic  wall,   181 

of  thyroid  gland,   154 

of  tongue,   109 

of  tonsil,   113,   115 

of  urethra,  418 
Nelaton's  line,  462,  475 
Nerves,  cranial,  injuries  of,  68 
Neutrophiles,  38 
Nipple,  diseases  of,  191 

eczema  of,   191 

Paget 's  disease  of,  191 
Noma,  106 


538 


INDEX 


Normoblasts,  37 

Nystagmus  in  cerebral  diseases  and 
injuries,   76 


Obstruction  of  oesophagus,  211 
Obturator  hernia,  238 
OEdema  of  abdominal  wall,   signs 
of,  223 
of  glottis,   162 
of  larynx,   162 
CEsophagoscope,  22,  215 
ffisophagus,  cancer  of,  oesophago- 
scopic  pictures  of,  215 
compression  of,  213 
dilatation  of,  210,  216 

differentiation  between  diver- 
ticulum and,  216 
diseases   of,    oesophagoscope   in, 

214 
diverticulum  of,  212 

differentiation  between  dilata- 
tion and,  216 
examination  of,   212 
injuries  of,  176 
neoplasms  of,  211,  217 
obstruction  of,  diagnosis  of,  211 
occlusion  of,  by  foreign  bodies, 

209 
paralysis  of,  209 
perforation  of,  216 
spasms  of,  213 

stricture  of,  oesophagoscopic  pic- 
tures of,  214 
stenosis  of,  210 
symptoms    of,    disturbances    in 

lumen  of,  210 
syphilis  of,  210 
Omentum,  neoplasms  of,  299 

torsion  of,  299 
Optical  aphasia,  80 
Osteitis  deformans,  451 
Osteomalacia,  450 
Osteomyelitis,  acute  infective,  439 
differential  diagnosis  of,  442 
in  exanthemata,  443 
joint  complications  in,  441, 
443 
chronic,  444 

diagnosis  of,  447 
syphilitic,  448 
tuberculous,  444,  448 
typhoidal,  449 
x-ray  in,  445 


Osteomyelitis  of  jaw-bones,  92 

subacute  infective,  443 
Ovaries,  chronic  inflammation  of, 
354 
neoplasms  of,  354 
tumors  of,  broad  ligament,  355 
diagnosis  of,  356 
differential,  356 
kinds  of,  359 
pedicle  of,  354 
retroligamentary,  355 
symptoms  of,  355 


Pachtdbrma  of  larynx,  168 
Paget's  disease  of  nipple,  191 
Palpation,  abdominal,  224 

of  appendix,  method  of,  285 
Pancreas,  abscess  of,  326 
calculi  in,  338 
chronic  inflammation  of,  327 

differential  diagnosis  of,  327 
cyst  of,  328 

ascites  with,  337 

causes  of,  335 

composition    of    contents    of, 

333 
differential  diagnosis  of,  336 
disturbed  gastric  motility  in, 

332 
fatty  stools  with,  331 
glycosuria  with,  331 
hydronephrosis  with,  332 
obstructive  jaundice  with,  332 
relation  of,  to  colon,  328 
to  stomach,  328 
fat  necrosis  in  diseases  of,  324 
hemorrhage  of,  326 
hemorrhagic    inflammation    of, 

325 
necrosis  of,  326 
neoplasms  of,  328 
position  of,  324 
relation   of,  to   enlargements  of 

stomach  and  colon,  324 
tumors  of,  337 

differential  diagnosis  of,  337 
Papilloma  of  bladder,  404,  407 
Paralysis,  Brown-Sequard,  524 
musculospiral,  438 
of  oesophagus,  209 
Paraphimosis,  423 
Parotid  gland,  abscess  of,  120 


INDEX 


539 


Parotid  gland,  acute  inflammation 
of,  120 
calculus  in,  118 
neoplasms  of,   121 
tumors  of,  120 
Patella,  fractures  of,  438,  479 
Penis,  benign  nodules  of,  425 
chancre  of,  423 
condylomata  of,  424 
herpes  of,  425 
Pericardium,  injuries  of,  174 
Periosteo-osteomyelitis   albumin- 

osa,  448 
Periosteum,  tumors  of,  97 
Peripleuritic  exudate,   197 
Periproctitis,  368 
Peristalsis,  227 

Peritoneal  cavity,  perforation  into, 
274 
differential  diagnosis  of,  279 
crepitation,  226 
septicaemia,  249 
Peritonitis,  acute  diffuse,  248 

constitutional  symptoms  of, 

248 
leukocyte  count  in,  248 
physical  signs  of,  248 
chronic  adhesive,  251 
causes  of,  251 
symptoms  of,  251 
circumscribed,  249 
cause  of,  249 
leukocyte  count  in,  249 
symptoms  of,  249 
differential  diagnosis  of,  250 
tuberculous,    differential   diag- 
nosis of,  252 
symptoms  of,  251 
Pharynx,  actinomycosis  of,  112 
cancer  of,  115 
neoplasms  of,   115 
syphilis  of,  112 
tuberculosis  of,  112 
Phimosis,  423 
Pleura,  empyema  of,  192 

differential  diagnosis  of,  191 
physical  signs  of,  195 
sacculated,   195 
injuries  of,  173 
Poikilocytes,  37 
Polypi  of  rectum,  363 
Pott's  disease,  499 
Pregnancy,  extrauterine,  decidual 
discharge  in,  351 
differential  diagnosis  of,  353 


Pregnancy,   extrauterine,    rupture 
of,  352 

symptoms  of,  351 

tubal  mole,  351 
Prostate  gland,  atrophy  of,  415 

calculi  in,  418 

cystoscopy  in  diseases  of,  416 

hypertrophy  of,  415 

inflammation  of,  413 

neoplasms  of,  418 

tuberculosis  of,  414 

tumors  of,  418 
Pseudoleuksemia,   133 

of  lymphatic  glands,  133 
Pyaemia  in  appendicitis,  290 
Pyloric  stenosis,  acquired,  270 

causes  of,  271 

congenital,  270 

gastric  motility  in,  270 

signs  of,  270 

size  of  stomach  in,  270 
Pyonephrosis,  388 
Pyopneumothorax,   197 
Pyosalpinx,  349 
Pyuria,  404,  412 

vesical,  differentiated  from  renal 

404 


R 


Radius,  dislocation  of,  472 

fracture  of,  438,  473 
Railway  spine,  522 
Ranula,   118 
Rectum,  atresia  of,  363 
examination  of,  361 
fistula  in,  368 
hemorrhoids,  causes  of,  365 

differential  diagnosis  of,  365 

varieties  of,  365 
inflammation  of,  366 
neoplasms  of,  367 
periproctitis,  368 
polypi  of,  368 
prolapse  of,  363 

differential  diagnosis  of,  364 
stricture  of,  367 

neoplastic,  368 

syphilitic,  368 
ulceration  of,  366 

amoebic,  366 

malignant,  367 

syphilitic,  367 

tuberculous,  367 

varicose,  367 


540 


INDEX 


Reflex  muscular  spasm  in  joint  dis- 
ease, 462 
with  pain,  30 
Retropharyngeal  abscess,  124 
Rhachitis,  450 

curvature  of  spine  in,  509 
Ribs,   cervical,  147 
fracture  of,   172 
Riedel's  lobe,  321 

in  cholelithiasis,  312 
Roentgen  machine,  21 
Rupture  of  spleen,  340 


Sacral  region,  cysts  of,  527 
Sacroiliac    joint,    tuberculosis    of, 

499 
Salivary  glands,  calculi  in,   118 
inflammation  of,  117 
syphilis  of,  119 
tuberculosis  of,  119 
tumors  of,  120 
Salpingitis.     See  Fallopian  tube. 
Sarcoma.     See  Neoplasm. 

of  kidney,  399 

of  lymphatic  glands,  135,  137 

of  tonsil,   113 
Scalp,  cysts  of,  58 
sebaceous,  58 

injuries  of,  77 

neoplasms  of,  59 
Schmidt-Monard  sign  of  hour-glass 

stomach,  273 
Scrotum.     See  Penis. 

swellings  of,  425 
Scurvy,  105 

Sebaceous  cyst  of  scalp,  58 
Seminal  vesiculitis,   413 
Septicaemia,  43,  46 

in  appendicitis,  290 

cryptogenetic,  47 

peritoneal,  249 
Serous  membranes,    inflammation 

of,  leukocyte  count  in,  40 
Shifting   dulness  in  abdomen,  252 
Shoulder-joint,  dislocation  of,  468 

examination  of,  467 

fractures  around,  469 

injuries  of,  467 

tuberculosis  of,  489 
Sinus  thrombosis,  aseptic,  81 
difl'erential  diagnosis  of,  84 
infective,  82 


Sinus  thrombosis,  localization  of, 

83 
Skull,  injuries  of,  77 
neoplasms  of,   63 
bones,  vessels  of,  aneurysm  of, 
64 
Smoky  urine,  370 
Soor,   104 

Spasm  of  larynx,  162 
of  oesophagus,  213 
Spermatic    cord,    hsematocele   of, 
427 
hsematoma  of,  427 
hydrocele  of,  427 
lipoma  of,  428 
varicocele  of,  428 
Spermatocele,  430 
Spina  bifida,  525 

ventosa,  448,  499 
Spinal  cord,   Brown-Sequard  par- 
alysis, 524 
compression  of,  523 
concussion  of,  522 

railway  spine,  522 
injuries  of,  521 
transverse    lesion    of,    incom- 
plete, 524 
Spleen,  abscess  of,  339 

concentric   obliteration    of   dul- 
ness of,  229 
injuries  of,  235 
in  leukaemia,  340 
movable,  339 
position  of,  339 
rupture  of,  340 
tumors  of,  340 
Sprains,  467 

of  wrist-joint,  474 
Stenosis  of  larynx,  161 
of  oesophagus,  210 
pyloric,  270 
Sternum,  fracture  of,   172 
Stomach.  See  also  Pyloric  stenosis, 
acute  dilatation  of,  271 
diseases  of,    gastrodiaphane   in, 

223 
distention  of,  259 

effect  of,  on  position  of  abdom- 
inal tumors,  229 
method  of  artificial,  228 
examination  of,   259 
exploratory     laparotomy     in, 

259 
hour-glass  condition  of,  272 
motility  of,  261 


INDEX 


541 


Stomach,  neoplasm  of,  265 
ani'emia  in,  267 
character  of  tvimor  in,  268 
differential   diagnosis   of, 
268 
diagnostic    laparotomy    in, 

267 
early  signs  of,  266 
gastric  juice  in,  266 

motility  in,  267 
palpation  of,  265 
perforation  of,  277 
ulcer  of,  262 

differential  diagnosis  of,  263 
gastric  juice  in,  262 
head  zone  in,  262 
perforation  of,  255 
Stomatitis,   104 
Stricture  of  larynx,  169 
of  oesophagus,  214 
of  rectum,  367 
of  ureter,  402 
of  urethra,  417 
Subhyoid  bursitis,  144 
Subnormal  temperatures,  35 
Subphrenic  abscess,  194,  255 
causes  of,  255 
differential     diagnosis    of, 

257 
pleural  exudate  with,  256 
signs  of,  255 
Succussion  over  abdomen,  229 

over  thorax,   197 
Surgical  kidnej^,  386 
Suppuration  of  breast,  184 
Suppurative  encephalitis,  97 
Syphilis  of  bones,  448 
of  breast,  185,  191 
of  epididymis,  433 
of  face,  88 
of  joints,  512 
of  larynx,   166 
of  liver,  312 

of  lymphatic  glands,   136 
of  mouth,  105 
of  oesophagus,  210 
of  pharynx,   112 
of  rectum,  368 
of  salivary  glands,  119 
of  skull  bones,  62 
of  testicle,  433 
of  thoracic  wall,  178 
of  tongue,   107 
of  tonsil,   112 
Syphilitic  arthritis,   512 


Tendon   sheaths,  tuberculosis  of, 

490,  498 
Testicle,  character  of  swellings  of, 
432 

inflammation  of,  432 

neoplasms  of,  434 

syphilis  of,  433 

tuberculosis  of,  434 
Tetanus,  45 

differential  diagnosis  of,  47 

head,  45 
Thoma-Zeiss  hsemocytometer,  35 
Thoracic   wall,    actinomycosis    of, 
178 
neoplasms  of,  181 
Thorax,  abscess  of,  178 

actinomycosis  of,  178 

aneurysm  of,  180 

concussion  of,  171 

emphysema  of  subcutaneous  tis- 
sues of,  173 

hsematoma  of,  172 

injuries  of,  173 

neoplasms  of,   181 

succussion  over,   197 

syphilis  of,   178 

tuberculosis  of,   178 
Thyroid  gland,  aberrant,  149 
neoplasms  of,   154 
tumors  of,  149 

characteristics  of,  149 
nature  of,   151 
Tibia,  fracture  of,  438,  480 
Tongue,  actinomycosis  of,   108 

cancer  of,  109 

inflammation  of,  106 

neoplasms  of,  109 

syphilis  of,  107 

tuberculosis  of,  107 
Tonsil,  abscess  of,  112 

actinomycosis  of,  112 

cancer  of,  115 

cyst  of,  112 

hyperplasia  of,   112 

neoplasins  of,  113,  115 

sarcoma  of,  113 

syphilis  of,  112,  115 

tuberculosis  of,  112 
TorticoUis,  510 

Trachea,  foreign  bodies  in,  163 
Tuberculosis  of  ankle-joint,  498 

of  articular  ends  of  bones,  early 
x-ray  signs  of,  463 


542 


INDEX 


Tuberculosis  of  astragalocalcanean 
joint,  499 

of  bladder,  403,  406 

of  bones,  444,  448 

of  breast,   185 

of  elbow-joint,  490 

of  epididymis,  434 

of  genitals,  423 

of  hip-joint,  491 

of  joints,  485 

of  kidney,  391 

of  knee-joint,  497 

of  larynx,   166 

leukocyte  count  in,  42 

of  lymph  glands,  132,  136 

of  pharynx,   112 

of  prostate,  414 

of  sacroiliac  joint,  499 

of  salivary  glands,  119 

of  shoulder- joint,  489 

of  skull  bones,  59 

of  small  intestine  and  ileocsecal 
region,  297 

of  tendon  sheaths,  490,  498 

of  testicle,  434 

of  thoracic  wall,   178 

of  tongue,   107 

of  tonsil,   112 

of  vertebrae,  449 

of  wrist-joint,  490 
Tuberculous  arthritis,  482,  484 
Tumors.     See  Neoplasms. 

abdominal,  mobility  of,  227 

of  abdominal  wall,  233 

adrenal,  400 

of  brain,  85 

of  bronchi,  202 

of  kidney,  398 

of  liA^er,  306 

of  lung,  202 

of  lymphatic  glands,  135 

medullary,  of  bones,  452 

of  ovaries,  355 

of  pancreas,  337 

of  parotid  gland,   120 

of  periosteum,  97 

of  prostate  gland,  418 

in  right  hypochondriac  and  epi- 
gastric regions,  327 

of  salivary  glands,  120 

of  spleen,  340 

of  thyroid  gland,  149 

of  umbilicus,  235 

of  ureter,  402 

of  urethra,  418 


Tumors  of  uterus,  345 
Typhoid,  osteomyelitis  in,  449 
perforation  in,  278 

leukocyte  count  in,  41 


U 


Ulceration  of  rectum,  366 
Ulcerative  appendicitis,  acute,  288. 

289 
Ulna,  dislocation  of,  472 

fracture  of,  438,  472 
Umbilicus,  granuloma  of,  235 
hernia  of,  239 
tumors  of,  235 
Ureter,  cystic  intraparietal  dilata- 
tion of,  383 
inflammations  of,  401 

differential  diagnosis  of,  401 
injuries  of,  401 
kinks  of,  402 
multiple,  382 
strictures  of,  402 
tumors  of,  402 
Ureteral  efflux,  376 
bloody,  376 

trickle,  376 
puriform  trickle,  376 
solid  pus  efflux,  376 
orifice  in  diseases  of  kidney,  374 
normal,  374 

in  painless  hsematuria,  375 
in  renal  calculi,  375 
neoplasms,  376 
tuberculosis,  375 
peristalsis,  376 
Urethra,  calculi  in,  418 
hsematoma  of,  420 
inflammations  of,  413 
injuries  of,  420 
neoplasms  of,  418 
stricture  of,  417 
tumors  of,  418 
Urinary  extravasation,  420 
fever,  421 
fistulse,  409 

stream,  changes  in  calibre  of,  411 
tardiness  in  starting,  411 
Urine,  cloudiness  of,  causes  of,  404 
differentiation  of,  404 
in  diseases  of  anterior  urethra, 
404 
of  bladder,  404 
of  kidney,  473 


INDEX 


543 


Urine    in     diseases     of     posterior 
urethra,  412 
oi'  prostate,  412 
of  seminal  vesicles,  412 
epithelial  cells  in,  405 
in  hydronephrosis  of  kidney,  389 
incontinence  of,  410 
in  nonnal  and  diseased  kidneys, 

373 
in  pj-onephrosis,  389 
retention  of,  410 
smoky,  370 

in  tumors  of  kidney,  398 
Uterus,  tumors  of,  fibroid,  345 

differential  diagnosis  of,  346 
malignant,  348 


Vacuole  giant  cells  in  pulmonary 

neoplasms,  202 
Varicocele,  428 
Vascular  bruits,  229 
Ventral  hernia,  241 
Vertebrae,  dislocation  of,  520 
fracture  of,  519 
tuberculosis  of,  499 
attitude  in,  503 
cold  abscess  in,  504 
differential  diagnosis  of,  505 
early  signs  of,  499 
Vesical    haematuria    differentiated 
from  urethral  and  renal,  405 
pyuria  differentiated  from  renal, 
404 


Volvulus.  See  Intestinal  obstruc- 
tion. 

Von  Eiselsberg's  sign  of  hour-glass 
stomach,  273 


W 

Wolfler's      sign    of      hour-glass 

stomach,  272 
Wounds  of  abdomen,  235 
infections,  43 

constitutional  symptoms  of,44 
leukocyte  count  in,  46 
local  lesions  of,  48 
Wrist-joint,  dislocation  of,  474 
examination  of,  473 
fracture  of  bones  of,  473 
relation    of    bony    prominences 

around,  473 
sprains  of,  474 
tuberculosis  of,  490 


X-RAY  in  cranial  hemise,  56 
in  diseases  of  bones,  445 
in  early   tuberculosis   of   bones, 

463 
in  fractures,  435 
in  renal  calculus,  395 
in  spinal  hernise,  525 
in  tumors  of  bronchi,  202 
in  vesical  calculus,  407 


J 

Date  Doe 

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COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  35  B45  C.I 

Surgical  diagnosis:  a  manual  for  student 


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